GET TO KNOW THE AUTHOR: Austin Rezigh is an Academy member and academic primary care physician.
How I pre-chart for a new patient to make a comprehensive problem list: 1. Look at reason for referral 2. Load or locate outside records, where ever they exist in your EMR. In Epic, you will “query” CareEverywhere. After loads, clear findings (orange/yellow alert bar that you will click on and work through) 3. History tab (med, surg, fam, social) 4. Problem list tab 5. Meds 6. DC sums 7. Notes/Encounters (filter by clinic if alot) 8. Outside records (like CareEverywhere) Notes/Encounters (filter by hospital/clinic if alot) 9. Labs & outside record labs (make note of incidentals) 10. Imaging & outside record imaging (make note of incidentals) 11. Media tab for outside records/other reports (such as PFTs if do not show up under results) Try to complete all in one go. If too detailed/taking too long (set yourself a timer!), just go back 1 year (less or more depending on scenario). If you can’t get through all of it, THAT IS OK! Just give yourself a reminder of how far you go in the process and each time you see the patient, try to work through a section.
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