Improving Patient Care

A Tool for Better Well-Woman Exams

You can use this encounter form to improve your documentation and your care.

Thomas J. Weida, MD

Covered in FPM Quiz

Tool inside

Thorough documentation is critical not only to proper reimbursement but also to good patient care. Unfortunately, it is often time-consuming and cumbersome. One simple solution our practice has implemented is a visit-specific encounter form.

How it works

Recently, our practice's main insurance carrier began to require extensive documentation for routine gynecological exams, including notes regarding pertinent negatives, to support billing codes for this service. In addition to needing to meet our carrier's new requirements, we also wanted to assist our physicians in collecting information about the patient's history and health concerns. Previously, collecting this information was the responsibility of the physicians or nursing staff and, if done completely, required up to half the appointment time allotted for a gynecological exam. As a result, our physicians had little time left for preventive counseling or patient education.

The encounter form we developed has met both of these needs. It has shifted the responsibility for collecting patients' health information to the patient, which gives our physicians more time during the encounter and engages the patient in his or her care, and it includes the pertinent negative findings required by our carrier, which improves our billing and reimbursement.

When the patient checks in at the front desk, the secretary hands the patient the form and asks her to complete it while she is waiting to be seen. The physician then performs the exam and documents the findings on the form. Checking the "normal" box indicates that a pertinent negative has been reviewed. Checking the "abnormal" box and circling the pertinent findings documents the physical findings. The form requires minimal handwriting by the physician and enables all documentation to be complete by the end of the visit.

Patients generally do not object to filling out the form, but we do get an occasional complaint. Our secretaries and physicians respond by encouraging patient participation in the process and stressing the importance of the information gathered. This message is reinforced when the physician actually uses the form during the visit to review the patient's information. If a patient does not complete the form, we do not make an issue of it. Our nursing staff helps those patients with sight or reading difficulties to complete the form.

Many of our physicians initially complained that there was not enough room on the form to document significant problems or additional medical issues. This was done intentionally. If documentation of the additional problem or finding takes up significant room, it is likely that the problem requires a significant, separately identifiable service that can be coded using the appropriate evaluation and management (E/M) office visit code and a supporting diagnosis code. By not building in room for this on the gynecological encounter form, we are encouraging our physicians to dictate a separate encounter note for the separate problem. This keeps the documentation very specific, and it is easy for reviewers to identify which parts of the exam correspond with the routine pelvic exam and which correspond with the E/M service.

Although not required for most carriers, exam documentation for all organ systems is included on our form; however, this is kept general in nature. Should the patient require a more comprehensive preventive history and physical, we use a commercially available history and physical form to document these areas.

Results

The gynecological encounter form has been well received by the physicians in our practice. Because the form covers most of the routine questions, the physicians can devote more time to patient education and counseling. Because the form prompts them to document all pertinent negative findings, our physicians are seeing reimbursement benefits as well. While a 30-minute visit never used to seem like enough time to do all that was required, our physicians now have time to be thorough in their care and in their documentation.

A PDF version of this document is available. Download PDF now (1 pages/ 47 KB). More information on using PDF files. WELL-WOMAN EXAM Patient's name: ______________________ Patient section: Please answer the following questions. This will help your physician identify possible problems. Your age: _______ When was your last mammogram? ____________ When was your last period? ____________ When was your last PAP test? 1 yr 2 yrs >3 yrs Were the results normal? Yes No Have you ever had an abnormal PAP test? Yes No How often do you usually get your period? every ____ days Are your periods usually regular? Yes No How many days do your periods usually last? _____ days The blood flow is: Light Moderate Heavy Do you have any bleeding between periods? Yes No Do you have any vaginal discharge? Yes No Are you sexually active? Yes No If yes, do you and your partner use birth control? Yes No Method: ________________________ Have you ever had a sexually transmitted disease? Yes No Has your mother ever been exposed to DES? Yes No Have you ever used fertility medicines? Yes No Do you have hot flashes? Yes No Are you on hormone replacement? Yes No Do you smoke? Yes No How often do you perform self breast-exams? Less often than monthly Monthly Do you have a history of breast problems? Yes No Have you ever been abused? Yes No Do you feel safe? Yes No Is there any family history of: Breast cancer? Yes No Colon cancer? Yes No Uterine cancer? Yes No Ovarian cancer? Yes No Other cancers? Yes No Osteoporosis? Yes No Heart disease? Yes No Do you have any allergies? Yes No (list them below) On a scale of 0 to 10, with 0 being no symptoms and 10 being severe symptoms, how would you describe the following (please circle): Pain during your usual period: 0 1 2 3 4 5 6 7 8 9 10 Pain during sex: 0 1 2 3 4 5 6 7 8 9 10 PMS (premenstrual tension syndrome): 0 1 2 3 4 5 6 7 8 9 10 If you have been pregnant, please indicate how many: Pregnancies ____ Full-term live births ____ Premature births ____ Abortions ____ Living children ____ Please list any other concerns: __________________ Physician section: Abnormals should be described below or on the reverse side of this form. For VS and allergies, see separate note in chart. Nl Abn   Nl Abn   HEENT ABDOMEN THYROID SKIN LUNGS EXTREMITIES HEART NEURO If there are any abnormalities, circle the specific one(s) and describe below or on reverse. Nl Abn   BREAST Masses, Lumps, Tenderness, Symmetry, Nipple discharge, Axilla EXTERNAL GENITALIA Appearance, Hair distribution, Lesions URETHRA & MEATUS Size, Location, Lesions, Prolapse, Masses, Tenderness, Scarring VAGINA Appearance, Estrogen effect for age/meds, Discharge, Lesions, Pelvic support, Cystocele, Rectocele CERVIX Appearance, Lesions, Discharge UTERUS Size, Contour, Position, Mobility, Tenderness, Consistency, Support ADNEXA Masses, Tenderness, Organomegaly, Nodularity BLADDER Fullness, Masses, Tenderness ANUS & PERINEUM RECTAL Tone, Hemorrhoids, Masses HEMOCCULT KOH/WET PREP ACETIC ACID WASH _____________________________ _____________________________ A:  Normal gyn/pap  Family Planning  Pregnancy  HRT P:  Pap  HRT info given  Caffeine ed  Stool OB  BSE info  Flex sig  Calcium ed  Mammogram ______  Dexa  Heel  Full Return for pap 1 year or ________ RTC ________ Developed by the Milton S. Hershey Medical Center, Hershey, Pa. Copyright © 2002 American Academy of Family Physicians. Physicians may photocopy for use in their practices; all other rights reserved. Family Practice Management, April 2002:51-52; www.aafp.org/fpm/20020400/51atoo.html.

Dr. Weida is an associate professor in the Department of Family and Community Medicine, Pennsylvania State College of Medicine, Hershey Medical Center, in Hershey, Pa. He is also a member of the FPM Board of Editors. Conflicts of interest: none reported. The author wishes to thank Phyllis Hare of the Department of Family and Community Medicine for her assistance with CPT coding issues.

Send comments to fpmedit@aafp.org.