Briefing: A Doctor’s View of AHLTA Date: 22 March 2007 Time: 1510-1600

1. Briefing: A Doctor’s View of AHLTA Date: 22 March 2007 Time: 1510-1600

2. Objectives • Quick overview of documentation types • Demonstrate how providers document in Ahlta • Walk through the sections in relationship to the coding calculator • Plea for help!

3. Notes on Notes! • SOAP note • Most commonly taught (and used) note • 4 sections • Problem-oriented note • All information about each diagnosis (or “problem”) is documented under that diagnosis • Used when patient has many problems • History and physical • Used more for inpatient admissions • Most detailed of the notes

4. Notes on Notes! • SOAP notes are ingrained in provider’s minds • Providers don’t like change • Ahlta splits our notes into three main sections • S/O • Either very heavy structure or no structure at all • Can’t order the note (today) • A/P • Divided by diagnosis • Much more similar to a problem-oriented note • Everything else! • Screening, vitals, add note, drawing tool, disposition

5. Notes on Notes! • More AHLTA . . . • Many different users can document in an AHLTA note • Only the encounter owner can sign the note • Limited users can add diagnoses • Providers want more of the note entered by others • We are expensive data entry operators! • The Ahlta coding calculator is reasonably accurate • The rest of this talk is discussing the caveats to that!

6. Walking Through a Note • Auto-cites AutoCites Refreshed by USER, TEST @ 21 Feb 2007 1417 EST Problems Allergies • ESSENTIAL HYPERTENSION Aspirin: Anaphylaxis • METRORRHAGIA • IRON DEFICIENCY ANEMIA Active Medications Status Sig Refills Last Filled AMLODIPINE 5MG--PO 5MG TAB Active QD 6 of 6 Not Recorded HCTZ (ESIDREX/ORETIC)--PO 25MG TAB Active QD 6 of 6 Not Recorded FERROUS SULFATE--PO 325MG TAB Active 1 QD 6 of 6 Not Recorded • No credit (today) for information in Auto-cites

7. Walking Through a Note • Screening & Vitals Screening Written by USER, TEST @ 21 Feb 2007 1409 EST Reason For Appointment: cough & fever HTN followup Allergen information verified by USER, TEST @ 21 Feb 2007 1408 EST Reason(s) For Visit (Chief Complaint): IRON DEFICIENCY ANEMIA (Follow-Up) : Needs meds refilled; Comments: Free text comments in the screening module. Post-hysterectomy. Birth Control Method: NOT APPLICABLE (HYSTERECTOMY). Vitals Written by USER, TEST @ 21 Feb 2007 1409 EST BP: 120/80, HR: 88 Regular, Radial Artery, RR: 12, SpO2: 97%, Tobacco Use: No, Alcohol Use: Yes, Have you ever felt you should Cut down on your drinking? No, Have people Annoyed you by criticizing or complaining about your drinking? No, Have you ever felt bad or Guilty about your drinking? No, Have you ever had a drink or drug in the morning (Eye opener) to steady your nerves or to get rid of a hangover? No, Pain Scale: 0 Pain Free Comments: These are free-text comments in the Vitals module.

8. Walking Through a Note • Screening and Vitals • Entered by support staff (vast majority of the time) • No credit in the coding calculator for data here • Regardless of who put it in

9. Walking Through a Note • The Provider Portion • Medcin • AIM forms • Free text

10. Walking Through a Note • Medcin

11. Walking Through a Note • AIM Form

12. Walking Through a Note • History of Present Illness (HPI) • AHLTA gives credit for 4 bits (bullets or modifiers) • Surrogate for 4 elements of HPI. • Credit given regardless of who put it in the note SO Note Written by USER, TEST @ 21 Feb 2007 1511 EST History of present illness The Patient is a 45 year old female. • Vomiting •  Mild abdominal pain for 2 days

13. Walking Through a Note • Past, Family and/or Social History • Located (mostly) under PMH tab in S/O module Past medical/surgical history Therapeutic History: Tonsillectomy Personal history Behavioral history: No tobacco use Family history Paternal history of: Asthma • Credit is also given for diagnoses in A/P • E.g., Family history of malignant neoplasm of the large intestine

14. Walking Through a Note • Review of Systems (ROS) Review of systems Systemic symptoms: No fever Head symptoms: No headache Otolaryngeal symptoms: Recent nasal discharge that doesn't bother the patient Genitourinary symptoms: No hematuria Neurological symptoms: No dizziness • Most common reason for a 99211 is a lack of items in this section. • We teach providers to put positives in HPI and negatives in ROS (as a rule)

15. Walking Through a Note • Physical Exam • 1997 guidelines used • Providers can pick single system exams in the disposition module • Division in note is not the same as coding guidelines division! • We encourage templates to be built with coding guidelines in mind

16. Walking Through a Note • Physical Exam • Default template is key! • This is an area where YOU can help us out

17. Walking Through a Note • Physical Exam Nose: ° No tenderness of the sinus Oral cavity: Buccal Mucosa: ° Not dry Pharynx: Oropharynx: • Posterior pharyngeal wall was markedly erythematous ° Posterior pharyngeal wall did not have an exudate Musculoskeletal system: Leg (Below Knee): Left leg: ° Achilles tendon was not tender on palpation Ankle: Left ankle: ° No tenderness on palpation of the medial aspect ° No tenderness on palpation of the lateral aspect ° Ankle did not show laxity Neurological: Gait And Stance: ° Normal

18. Walking Through a Note • A/P Module

19. Walking Through a Note • A/P Module • Diagnoses here are based on what we (as providers) have always documented • This occasionally generates incorrect ADM records • Providers care about documentation, not ADM records! • Diagnoses are taken into the coding calculator • Other Therapies are taken into the coding calculator • Orders (today) are not • Lots of free text in this area

20. Walking Through a Note A/P Written by USER, TEST @ 23 Feb 2007 1127 EST 1. DIABETES MELLITUS TYPE II Patient Instruction(s): -Dietary Counseling Pertaining To Specific Condition 2. HYPERLIPIDEMIA Laboratory(ies): -LIPID PANEL-COMPLETE (Routine) Start Date: 02/23/2007 Order Date: 02/23/2007 11:27 3. ESSENTIAL HYPERTENSION: Father had HTN at an early age, so she isn't surprised by this diagnosis. Stressed the importance of decreasing sodium intake and encouraged weight loss. Procedure(s): -Electrocardiogram Medication(s): -LISINOPRIL (PRINIVIL/ZESTRIL)--PO 40MG T - TAKE 1 TAB PO EVERY DAY Qt: 60 Rf: 0 Start Date: 02/23/2007 Order Date: 02/23/2007 11:26

21. Walking Through a Note • Diagnosis

22. Walking Through a Note • Procedures

23. Walking Through a Note • Procedures • Help us with this list!

24. Walking Through a Note • Disposition

25. Walking Through a Note • Disposition • Time Factor is most abused section • Service Type is only as accurate as CHCS • “Why did it give credit for that?”

26. Walking Through a Note • “Why did it give credit for that?”

27. Walking Through a Note • Disposition • Selection Tab

28. A Quick Tease • Coding Calculator is Changing in 3.3

29. A Plea for Help! • What things can YOU do when you get back home to help providers? • Populate favorites list with what we should be using • Tell us which codes we shouldn’t use (and should take out of our templates) • Tell us what we’re missing (and should add in our templates) • Don’t tell us our documentation is wrong! • It’s OK to tell us that you disagree with the ADM record generated • ADM is the “System of Record” for billing, change the codes there as you may

30. Summary • AHLTA notes take on all shapes and sizes • Seeing where the data was entered helps you to understand the ADM that was generated • YOU can help US code more accurately!

31. Quiz • True / False • The only place where Ahlta gives credit for history elements is in the SO Module • Credit is never given for Free Text • Providers care about coding