What is an alternative way to document a follow-up visit?

Alternative Documentation Methods for Follow-Up Visits

The most effective alternative to traditional narrative documentation is using structured templates with pre-populated fields that capture essential clinical elements while reducing documentation burden and improving information retrieval. 1

Structured Template Approach

Structured templates built on standardized coding systems represent the optimal alternative documentation method, as they facilitate comprehensive data capture during routine care delivery while enabling comparative analysis and quality improvement tracking. 2

Core Template Components

The American Heart Association and American Academy of Pediatrics recommend that follow-up visit templates include these essential structured elements: 1

• Patient Assessment Section: Interval history with new symptoms, functional status changes across domains (home, work, school), and medication reconciliation with adherence assessment 1
• Objective Measurements: Vital signs, weight trends, and relevant physical examination findings specific to the patient's conditions 1
• Clinical Decision Documentation: Assessment of treatment response, medication management plan updates, and lifestyle modification recommendations 1
• Patient Education Record: Documentation of instructions provided regarding medications, symptom recognition, diet counseling, and activity recommendations 1
• Follow-Up Planning: Specific timeframe for next visit and identification of issues requiring monitoring 1

Patient Datasheet System

An alternative comprehensive approach utilizes a patient datasheet combined with generic evaluation sheets that provides quick access to pertinent medical information while preventing repetitive documentation of stable information like medication lists. 3 This system:

• Facilitates rapid review of patient medical history without searching through multiple notes 3
• Improves transmission of instructions to patients 3
• Simplifies record-keeping by avoiding rewriting of repetitive information after each visit 3
• Enables easy tracking of medication history changes over time 3

XML-Based Structured Data Entry

For organizations with advanced EHR capabilities, template-based data entry using XML structure allows general descriptions to be entered in structured format while simultaneously displaying as narrative text for readability. 4 This approach:

• Converts structured data to narrative form automatically for easy reading 4
• Stores data in both XML and narrative formats 4
• Enables data extraction to data warehouses for clinical research and quality improvement 4

Disease-Specific Follow-Up Documentation

Ophthalmology Follow-Up (Macular Conditions)

For patients with macular holes or age-related macular degeneration, follow-up documentation should include: 5

• Interval history: New symptoms including decreased vision and metamorphopsia 5
• Visual acuity measurement at distance with correction 5
• Amsler grid testing 5
• IOP measurement 5
• Slit-lamp biomicroscopy of anterior chamber and central retina 5
• OCT imaging to document postoperative macular anatomy when indicated 5

Heart Failure Follow-Up

The American College of Cardiology/American Heart Association specifies that heart failure follow-up documentation should capture: 5

• Patient history with functional status assessment 5
• Physical examination findings 5
• Laboratory or other test results 5
• Plan for follow-up care with specific date documented 5

Diabetes Hospital Discharge Documentation

For diabetes patients transitioning from hospital, structured discharge communication must include: 5

• Medication reconciliation ensuring no chronic medications were stopped 5
• Discharge summary transmitted to primary physician as soon as possible 5
• Scheduled follow-up appointments arranged prior to discharge with appropriate professionals 5

Implementation Best Practices

Template design should minimize documentation burden while capturing essential information, with regular updates based on changing guidelines and evidence. 1 Key considerations include:

• Balance between structured data entry and narrative information to maintain clinical context 1
• Integration of decision support tools when available 1
• Use of patient-friendly language in education materials 1
• Training for clinicians on proper template use 1
• Feedback mechanisms for continuous template improvement 1

Common Pitfalls to Avoid

Avoid creating templates that simply replicate free-text documentation without providing structured data fields that enable analysis and quality tracking. 2 Additionally:

• Do not include excessive sections that clinicians find superfluous (such as comprehensive Review of Systems for every visit) 6
• Prioritize placement of Assessment and Plan sections prominently, as these are most frequently referenced by physicians 6
• Ensure medication lists are maintained in a central location rather than rewritten with each visit 3