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 a list of the patient's health conditions organized in a Problem List. Clinicians can better track treatments and trends for multiple evolving issues

Problems are attached to patients. When POC is used across care contexts -- including inpatient, emergency, critical and outpatient care -- teams can better coordinate disease management. 

Charting Context

This section focuses on use of POC tools in Connect Care during inpatient encounters. Similar tools are available during outpatient encounters and the similar workflows apply. However, a few differences deserve attention:

Otherwise, all POC tools serve all patient encounters and all prescriber jobs have access to the tools. Specialties like Anesthesiology would not, typically, adopt problem oriented charting. Specialties with single-problem focus may not find value. Surgical specialties may elect to use POC only for post-operative care of complex hospitalized patients where hospitalist support is available.

Charting Compact as a Condition for POC Adoption

A necessary condition for POC is effective Problem List management. 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.

Problem oriented charting is a "team sport". It leverages shared documentation to decrease information burdens for all. Accordingly, clinicians adopting POC individually, without assurance that colleagues will manage problems at transitions of care, may suffer extra work in continually re-asserting POC methods when on service.

The first step to POC adoption is for a clinical team to agree to use the Connect Care POC toolkit. 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, or by using the chart sidebar index ("problem charting" item). As a favourited activity, the POC navigator will be in the foreground of every opened chart. 

Getting Started

Once a decision is made to adopt problem-oriented charting, all team members should complete some self-directed training. The following module explains POC best practices with illustrated tips and scripts. These are most useful when habituating to POC during admission, daily rounds and discharge or transfer.

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 in the sections 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. Note that, because outpatient visits are already specialty-specific, there is no need to set the specialty service in an ambulatory context.

Patient Overview or Presentation

Documentation can benefit from standardization of frequently used text blocks. These can be pulled into one or more summative or progress notes. Interactive previews of these text blocks, are provided in POC Side Bar displays. The "Patient Presentation" is one such block. It automatically adapts wording to inpatient, emergency and outpatient contexts.

Patient Care Coordination Note

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.

Problem Overviews

Problem Assessment & PIan Notes

Generate Progress 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.

Generate Summative Documentation

AHS standardized templates are provided in Connect Care for the major summative documentation types (History & Physical, Consult, Discharge Summary, etc.). These can be accessed from within navigators, by looking up SmartText templates, or by using the "Notes" item from inpatient or outpatient sidebar indexes.

The standard templates are offered at three levels:

Teams adopting problem oriented charting should chose the "Advanced" templates for progress and summative documentation.