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.
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:
Whereas inpatient POC progress notes are assembled from a "Subjective & Objective" section blended with one or more problem assessment and plan section(s), outpatient POC progress notes do not have a separate subjective & objective component. Outpatient problem notes (with subjective & objective observations contained) are recorded for problem addressed during the visit, then assembled into a combined progress note.
Hospital Course note
Outpatient encounters are shorter and usually self-contained. Accordinly, the Wiki-like hospital course note used for inpatient encounters does not have an equivalent for outpatient documentation.
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.
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:
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".
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.
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.
This button assembles the information entered in other parts of the POC navigator to compose a progress note in problem-oriented charting format.
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 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.
Purpose: The patient presentation gives a one-sentence summary snapshot of where the patient comes from, how they presented, what the chief complaint was and why they were admitted or seen in consultation.
Context: Rules are used to generate prose that befits admissions, consultations or outpatient visits.
Sharing: The structured data used to generate a presentation text block is exposed to all specialties and teams participating in a patient's inpatient care.
Style: Single-sentence prose with interactive (dark blue) text sections that can be clicked to open a form for editing underlying structured data.
Use: Typically the first sentence (overview, presentation, etc.) of summative documentation and optionally insertable into progress documentation.
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.
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.
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.
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.
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:
Headings - optimized for dictation or for creating SmartPhrase personalizations
Basic - leverages compliance with minimum use norms, pulling in basic structured data like problem, medication and allergy lists.
Advanced - optimized for problem-oriented charting, pulling in the text blocks described above.
Teams adopting problem oriented charting should chose the "Advanced" templates for progress and summative documentation.