Problem Oriented Charting

Problem Oriented Charting (POC) is an approach to clinical documentation that emphasizes what is new and important in a patient's healthcare experience, keyed to health conditions listed in a Problem List. POC is particularly attractive for inpatient charting. Clinicians can better track treatments and trends for multiple issues evolving over time. Problems are attached to patients. When POC is used across all contexts -- including inpatient, emergency, critical and outpatient care -- teams can better coordinate chronic disease management. 

This section focuses on use of POC tools in inpatient, emergency and critical care settings.

Getting Started

A necessary condition for POC is Problem List management. At a minimum, patients' problem lists should be updated at admission and discharge. Adoption of POC should not be considered until clinical teams have achieved at least 80% compliance with problem list minimum use norms. This assures familiarity with standard problem list workflows, including how those tools figure in admission, discharge and transfer navigators.

The first step to POC adoption is for a clinical team to agree to use of the POC toolkit. POC benefits from teamwork, assumes that teams share documentation tasks, and promises decreased documentation burdens for all. Team members should familiarize themselves with the tools and skills described here. 

Once a team documentation "compact" (shared understanding of which tools are used by whom and when) is affirmed, all team members should add the "Problem Oriented Charting" activity to their default inpatient chart tabs. The POC activity is found on the chart activities menu, or by using "problem oriented" keywords in chart search. As a favourited activity, the POC navigator will be in the foreground of every inpatient chart. 

Different teams can maintain separate documentation streams within POC. This allows consulting specialties, for example, to have different assessment and plan notes from the ones used by the home (attending) team. This also means that clinicians must enter their team name in the "Select Hospital Service" pick-list the first time that a patient chart is opened in a particular inpatient encounter.

POC Navigator Sections

The POC activity has sections that are organized vertically. These are accessed by scrolling or by using a left-column menu to choose from the available sections, which include:

The sections that most relate to POC are further described below.

Select Hospital Service

This section of the POC navigator is critical to the functioning of all other sections. POC tools are configured so that each hospital service (e.g., General Internal Medicine, General Surgery, etc.) works with its own subjective-objective note and its own problem-based assessments and plans. Anyone within a service can collaboratively update the subjective, objective, assessment and plan POC charting elements. Consequently, until the correct hospital service (the note authoring team) is selected, POC optimized charting tools are not available. 

Once a user has created at least one POC progress note using the POC navigator, subsequent visits to the same patient chart in the same inpatient encounter will see the Hospital Service conveniently pre-selected.

Connect Care is used by many specialties and more than one specialty may contribute to a patient's care at a time. POC tools facilitate this by keeping coordination and overview notes shared while assessment and plan notes are specialty-specific. 

Hospital Course

Subjective & Objective Note

This section of the POC navigator facilitates the creation, review and editing of a Subjective & Objective ("S&O") component to be used in a POC progress note. As indicated by its title, patient reported symptoms ("Subjective") and clinician observed signs ("Objective")  represent standard elements of an "APSO"-formatted (Assessment, Plan, Subjective, Objective) progress note; a standard layout adopted by AHS for Connect Care use.

The section displays any recent ("last") S&O note filed by the selected hospital service for the current patient and encounter. A "Current" S&O note can be created by clicking on the add (+) button. It remains current until a POC progress note is generated and signed, then becomes the "last" S&O note.

Patient Care Coordination Note

Problem Overviews

Problem Assessment & PIan Notes

Generate Note

Once a current Subjective & Objective entry and one or more problem-linked Assessment & Plan entries are available, the "Generate Note" button can be used to initiate a progress note in the APSO format that adheres to Connect Care provincial progress documentation standards.

Other POC Text Blocks

Documentation associated with patient encounters can benefit from standardization of frequently used text blocks which may be pulled into one or more summative or progress documentation templates. Interactive previews of these text blocks, are usually provided in Side Bar POC displays. Common text blocks include:

Inpatient Presentation (.PRESENTATION)

Pulling it all together: Documentation Templates