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:

  • 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 tool is used to record key developments occurring during a patient's admission. Resolved problems can be summarized alongside milestones in a course of illness. The Hospital Course is pulled into 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), and one or more periodic Assessment and Plan notes to document progress.

  • Generate Note
    This button assembles the information entered in other parts of the POC navigator to compose a progress note in problem-oriented charting format.

  • 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.

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

  • 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, persist until discharge, 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 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 infections, and rehabilitative progress. Think of the hospital course as a gradually emerging core of a discharge or transfer summary.
    At first access, the hospital course note is initiated with a standardized introductory block of text. This can be deleted in favour of an alternate personal preference. If used, the starter-block has "hot spots" (dark blue text links and wildcards [***]) that can be selected to bring up an edit tool for setting values for the missing text. This data is available for re-use elsewhere in problem oriented charting.


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

  • 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. Care Coordination notes are especially helpful for patients with complex illness receiving care from many providers. The note can clarify provider contributions and accountabilities while also referencing care plans, care paths or extraordinary care plans that all providers should align with.

  • 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. It can be accessed and edited from Problem List and Care Teams activities during any encounter.

  • 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 and should be short and compact.

  • SmartLink: .CARECOORD

Problem Overviews

  • 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.

  • SmartStuff: ".OVERVIEW..." (look up standardized problem overviews by starting SmartPhrase searches with ".OVER")

  • More information:

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.

  • Links:

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)

  • Content: Combines information about a patient's reason for presentation, reason for admission and the mode of presentation from where.

  • Data: Embedded data elements are exposed through SmartLinks and can be used in reports or decision supports.

  • Interaction: The text block is adjusted to fix the current patient's circumstances by clicking on any text coloured dark blue.

Pulling it all together: Documentation Templates