Problem Oriented Charting

Problem Oriented Charting (POC) is an approach to clinical documentation that allows progress to be described in terms of the health conditions listed in a patient's Problem List, rather than in terms of encounters or visits. POC is particularly attractive for inpatient charting. Clinicians can better track treatments and trends for multiple issues over time. They can also more find information about the evolution of individual problems.

Indeed, when POC is consistently adopted in all contexts -- including inpatient, emergency, critical and outpatient care -- teams can better coordinate care across the continuum of care. Problems are attached to patients. POC, with its coordination notes, hospital notes, problem overviews and assessments and plan notes, optimally preserves the patient's story across complex health journeys.

Connect Care is used by many specialties. POC will take time to take hold in diverse outpatient settings, where traditional consultation letters prevail as the unit of documentation. Accordingly, this section promotes use of POC in inpatient settings, where there is a more immediate fit.

Getting Started

A necessary condition for POC is effective Problem List management. POC can be considered when clinical teams that have achieved at least 80% problem list reconciliation at admission and discharge. This assures familiarity with the default "Problem List" activity in inpatient charts, as well as admission, discharge and transfer navigator variants.

The first step to POC adoption is for a clinical team to agree to switch to the POC paradigm. POC benefits from teamwork, saving documentation time for all. It is difficult to mix documentation strategies. Team members should ensure comfort with the skills described in this section and the linked Tips.

Once a documentation "compact" is affirmed, all team members should add the "Problem Oriented Charting" activity to their default list of inpatient chart tabs. The POC activity can also be found by using "problem oriented" in chart search. As a favourited activity, it will present with 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 organized vertically. These can be accessed by scrolling or by using a left column to choose among section title links.

  • Overview
    This provides a brief description of the POC activity together with links to this Manual section and associated Tips.

  • Select Hospital Service
    Pick-list that must be used at least once for an encounter-provider-patient intersect. Services can have different POC "channels".

  • Hospital Course
    This Wiki-like note tool is used to record key developments in a patient's admission. Resolved problems can be summarized here with milestones of the associated course of illness. The Hospital Course is pulled into standard discharge summary templates.

  • Subjective & Objective Note
    A new S&O note can be entered for each day that inpatient progress is documented. This combines all subjective (patient symptoms) and objective (clinician observations and results) unique or trending for that day.

  • Patient Care Coordination Note
    Care Coordination notes support patient-level longitudinal documentation about overall health status and how health problems relate to one another.

  • Problem Notes
    Each problem in the Problem List section supports one Problem Overview (succinct summary of key features of the problem for the patient, crossing all encounters), one or more related Patient Goals and one or more periodic Assessment and Plan notes to document progress.

  • History
    Medical, Surgical, Family and Social History summaries help clinicians when problems are moved between the Problem List and Medical History instead of newly entered or resolved.

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

Patient Care Coordination Note

  • Purpose: Patient Care Coordination notes provide a general introduction to a patient, including considerations that affect all health problems. These notes can help all clinicians get up to speed about a patient's condition, including aspects of care not covered in problem overviews or assessment and plan notes.

  • Context: Coordination notes are at a patient level and span all encounters and episodes. There is only one Care Coordination note per patient, with no specialty-specific variants.

  • Sharing: A singled Patient Care Coordination note is shared by all clinicians in all care contexts.

  • Style: An ideal note will be succinct, emphasizing the most important "meta" considerations that could be important to any provider and to any problem. One or two paragraphs should be sufficient, and simple prose is ideal. These notes should not be used for specialty or discipline-specific documentation, should not draw upon complex text automations, should never pull in results or other notes, and should ideally be authored with a generalist perspective.

  • Use: Some "interventions" (e.g., a prescribed diet) affect multiple problems and should be flagged at the level of the patient, not problem. Coordination notes can be used to highlight interdependencies between problems, including how one problem may limit the treatment options available to manage another problem. Ideally, these notes are relatively stable. They may be pulled in to all standardized summative documentation tools.

  • Link:

Hospital Course Note

  • Purpose: Hospital course notes allow clinicians to keep a running summary of the patient's inpatient experience that is eventually used as the start of a discharge summary.

  • Context: Anchored to inpatient encounters with each encounter having its own note, Hospital Course notes become visible upon admission and are not presented in ED or ambulatory contexts.

  • Sharing: Hospital Course notes are shared. The same note is exposed to all specialties and teams participating in a patient's inpatient care. All can edit the same note or individual(s) can be assigned accountability.

  • Style: Consider using bullet points to itemize key milestones or developments, as this can improve quick readability.

  • Use: In Wiki-like fashion, the Hospital Course note can be started at admission and continually updated throughout an inpatient stay. This tells the story of a patient's admission, with key milestones identified. These might include the dates and durations of any critical care transfers, onset and course of treated infections (including hospital acquired), and rehabilitative progress. Think of this note as a gradually emerging core of the discharge or transfer summary.


Problem Overview Notes

  • Purpose: Problem overview notes provide a high-level summary of the key attributes of a problem and approach to management. For example, the last ejection fraction may be specified for a HFrEF (Heart Failure Reduced Ejection Fraction) problem together with the fact that the patient's functional status is NY Class IV despite triple therapy and management in a heart failure clinic.

  • Context: Overview notes cross all encounters in all characteristics. They represent the intersect of patient and problem.

  • Sharing: Overview notes are shared. There are not specialty-specific variants.

  • Style: A short paragraph should be more than sufficient, ideally maintained and updated over time so that the overview represents the patient's current status for a particular problem and any key milestones or events experienced since the problem was first noted.

  • Use: In Wiki-like fashion, the problem overview can start when a problem is first entered. Over time, the problem details (e.g., precision of diagnostic code and description) while retaining the overview. Overviews are lost if a problem is deleted or moved to Medical History. They can be recovered if a problem is resolved.

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Problem Assessment & PIan Notes

  • Purpose: Problem assessment and plan (A&P) notes are time-specific documentations of the current status and details of management for a problem. There can be many A&P notes for each problem and they accumulate in a history over time.

  • Context: A&P notes are specific to a current evaluation point, usually a day that the associated problem is active in an inpatient admission. The history of past versions of A&P notes can span multiple encounters.

  • Sharing: Each specialty has its own set of A&P notes, but each problem-specific A&P note is shared by all members of the specialty team.

  • Style: Consider making the Assessment prose as a standard sentence/paragraph and entering the Plan prose as a bullet item(s).

  • Use: A new A&P note should be created each time a patient is evaluated for the associated problem. The content of an A&P note will vary over time, reflecting the progression of a problem from an early undifferentiated symptom through diagnosis, management and recovery or rehabilitation. A&P notes are lost if a problem is deleted or moved to Medical History. They can be recovered if a problem is resolved. A&P notes should be thought of as a marshalling tool for progress or summative documentation that will pull the latest A&P note.

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