Problem Oriented Charting Skills

Problem Oriented Charting (POC, poc.connect-care.ca) is an approach to clinical documentation that emphasizes what links new and important health developments to patients' health conditions organized in a Problem List. Clinicians can track multiple evolving issues. They do this collaboratively and so reduce the information burden shouldered by any one clinician. 

Gaining proficiency in problem list management is a prerequisite for problem oriented charting. Additionally, clinical groups should jointly adopt POC workflows. Once a "charting compact" is endorsed, all team members should complete self-directed POC training. This section supports that need with illustrated tips for admission, daily rounds, discharge or outpatient documentation.

Problem Oriented Charting Tips and Demos

POC workflows can seem daunting at first. With a little habituation, documentation burdens are reduced and more than compensate for the time invested learning new skills. The following tips illustrate little things that can make POC easier and more impactful. Most tips include short video demonstrations (1-3 min each; those who prefer visual learning can focus on the demo links in square brackets below).

A few online presentations explain the rationale for and approach to POC:

• Presentation: POC for Hospitalists (Calgary Zone)

The POC tips are listed, in order:

• Finding Problem Oriented Charting (POC) tools

  • Tip: Finding POC Tools - Inpatient [Demo]

  • Tip: Finding POC Tools - Outpatient [Demo]

  • Tip: Using the POC Sidebar [Demo]

• Shared documentation building blocks

  • Tip: POC Building Blocks [Demo]

  • Tip: Interactive Charting [Demo]

  • Tip: Patient Presentation [Demo]

  • Tip: Hospital Course [Demo]

  • Tip: POC Specialty Service [Demo]

  • Tip: Problem Overviews [Demo]

• POC Progress Notes

  • Tip: Subjective/Objective Documentation [Demo]

  • Tip: Assessment/Plan Documentation [Demo]

  • Tip: Generating a POC Progress Note [Demo]

• POC Summative Documentation

  • Tip: Generating Summative Documentation [Demo]

Other Street Smart Skills

• Module: Building a Better Health Record

• Module: Sidebar Tools

• Module: Problem List Management

• Module: Problem Oriented Charting

• Module: Discharge Planning Package

Resources

• • Norms: Documentation (Prescribers)

  • Manual: Problem Oriented Charting