J Clin Outcomes Manage
The problem-integrated charting system: a symbol-enhanced method of longitudinal record keeping for complex patients
Abstract Objective: To develop an effective method of charting for the long-term care of complex patients. Methods: Trial and error in an underserved nursing home practice using methods described by Weed and consistent with recommendations in the Institute of Medicineís Chasm report. Results: The system requires that the practitioner construct a summary of the patientís complex record and present it on a single visual field. Symbols, marks, and abbreviations are used to concisely represent information about conditions and treatments. The summary is a tool to be used when planning long-term care and is meant to be updated over time. The system includes progress notes that are concise narratives that focus on indicating clinical information rather than restating it. The designed interaction of the components reconciles precision with brevity. Conclusions: Utilizing the system ameliorates many of the limitations of the human mind when dealing with multiple comorbidities and reduces undesirable redundancy. The system could lessen the impact of technologic impoverishment for practitioners still using paper records and has the potential to be utilized in electronic medical records. Feedback and guidance from Medicare audit will be crucial prior to widespread application of the system.
Reports from the Field
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