Sep 2006 Table of Contents

The FPM Encounter Forms Collection: ‘Paper Automation’ of Your Progress Notes



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Our forms can make documentation faster, easier and more accurate while providing decision support and coding help. What more do you want for nothing?

Fam Pract Manag. 2006 Sep;13(8):63-68.

How is a preprinted encounter form like an electronic health record (EHR)? It’s the paper equivalent of the templates that many EHRs offer to facilitate data entry during the visit. And like EHR templates, encounter forms help in several ways:

  • They can make note taking faster and easier.

  • They can remind you to ask all the pertinent questions.

  • They can standardize your data collection – and standardize it across physicians in your practice.

  • They can facilitate coding and help prevent inadvertent downcoding.

  • They help ensure adequate documentation of the essential components of your code.

  • They can reduce or avoid dictation costs.

  • They can embody evidence-based guidelines and decision-support tools.

Of course, the computer can do things that paper can’t, and encounter forms have their disadvantages. For one thing, they tend to be special-purpose tools. To use them well you need an assortment on hand so you can pull out the correct one based on the patient’s complaint or other circumstances. In addition, they don’t easily accommodate multiple complaints. They don’t facilitate searching and analysis of the data they collect as much as template-based EHRs do. They may lead you to add a full sheet or more to the record with every visit, thus fattening up the chart. And incorporating them into your workflow and record keeping may require some creativity. Still, they offer a lot for your money, particularly if you can get them for nothing – which you can, from FPM.

ENCOUNTER FORMS IN THE FPM TOOLBOX

The forms listed below can be downloaded from the FPM Toolbox at http://www.aafp.org/fpm/toolbox or by clicking on the file format links below. In the toolbox, you will find links to available versions as well as links to the source articles, which offer helpful advice about putting the encounter forms to use. Click below to download one PDF file that contains all 18 encounter forms.

 Download in PDF format

Forms appropriate to certain clinical problems File formats

Acute knee injury*

PDF

Acute otitis media*

PDF

Asthma follow-up

PDF

Diabetes follow-up

PDF

Diabetes group visit

PDF, Word

Hypertension evaluation*

PDF

Pertussis exposure

PDF

Pulmonary embolism*

PDF

Sore throat*

PDF

Upper respiratory infection

PDF, Word

Forms appropriate to various visit types

Common skin procedures**

PDF

Evaluation and management services**

PDF

Home visit

PDF, Word

Nursing home group visit

PDF, Word

“Welcome to Medicare” exam**

PDF

Well-male visit

PDF

Well-woman visit (1-page version)

PDF

Well-woman visit (3-page version)

PDF


*Evidence-based decision-support tools from the Point-of-Care Guide series. For additional Point-of-Care Guides, see the collection available through the Web site of American Family Physician, our sister journal.

**Forms particularly intended to facilitate coding.

Forms appropriate to certain clinical problems File formats

Acute knee injury*

PDF

Acute otitis media*

PDF

Asthma follow-up

PDF

Diabetes follow-up

PDF

Diabetes group visit

PDF, Word

Hypertension evaluation*

PDF

Pertussis exposure

PDF

Pulmonary embolism*

PDF

Sore throat*

PDF

Upper respiratory infection

PDF, Word

Forms appropriate to various visit types

Common skin procedures**

PDF

Evaluation and management services**

PDF

Home visit

PDF, Word

Nursing home group visit

PDF, Word

“Welcome to Medicare” exam**

PDF

Well-male visit

PDF

Well-woman visit (1-page version)

PDF

Well-woman visit (3-page version)

PDF


*Evidence-based decision-support tools from the Point-of-Care Guide series. For additional Point-of-Care Guides, see the collection available through the Web site of American Family Physician, our sister journal.

**Forms particularly intended to facilitate coding.

Obtaining forms

Preprinted encounter forms are available from a number of sources, including commercial vendors such as Briggs Corporation (http://www.briggscorp.com/milcom.aspx), which offers Milcom forms, some reviewed and approved by the Society of Teachers of Family Medicine; Formedic (http://www.formedic.com), which offers free, advertising-supported forms; Records 1–2–3 (http://www.records123.com/), which was founded and is owned by a family physician; and T-System Inc. (http://www.tsystem.com/), whose forms are commonly called T-Sheets.

But if you want to see whether such forms would work well in your practice, why not start with some of the freely available forms in the FPM Toolbox online (http://www.aafp.org/fpm/toolbox)?

As the list suggests, the FPM encounter forms fall into two categories: those appropriate for various clinical problems and those appropriate for other special situations such as house calls and well-woman visits. Notes to the list point out several forms from our Point-of-Care Guides series that implement evidence-based decision support tools and others that have a special focus on improving coding.

Putting the forms to use

If you dictate your progress notes, encounter forms might provide an organized way of taking preliminary notes during the visit. You might even want to use the forms instead of dictating for visits where they apply. Why not save some transcription fees and have the note complete by the end of the visit? If you write progress notes by hand, you may find that the forms save you time as well as improve your documentation and coding by helping ensure that you capture the relevant information in an easily retrievable format.

In either case, the first challenge may be ensuring that the correct form is at hand when you need it. How to meet that challenge depends on your practice setup. For instance, you might want to keep multiple copies of the forms you use at a hallway work station. That way, the nurse or assistant who rooms the patient will be able to add the appropriate form to the chart based on the situation or the patient’s chief complaint. You might want to stock the forms in each exam room or even carry a small file case with you from room to room. Especially with these last two arrangements, it may be useful to stock patient information pertinent to the subjects of the encounter forms in the same place.

The second challenge is having a fallback plan when you don’t have a form that covers a given visit, as can happen even with an extensive collection of forms. You just won’t have a form for every contingency.

For these situations, the FPM collection includes a plain vanilla progress note form that can be used for any evaluation and management visit. It’s designed with a number of check boxes to facilitate taking the history and physical exam notes and coding the result. It also incorporates an ample area for handwritten notes.

Because of its general applicability, it’s reasonably adaptable to multiple-complaint visits – something that paper forms always have some difficulty handling with grace. Compared with many of the special-purpose forms, it also has the advantage of being just one page long; if you wish, you can make double-sided copies of it and save a little paper and chart space. You’ll find it online at http://www.aafp.org/fpm/2006/0900/emvisit.pdf.

Why not browse through the “Encounter Forms” section of the FPM Toolbox on our Web site? Just click the Encounter Forms link below the Toolbox graphic on the home page. The forms listed there are all available for you to use free of charge in your practice. If you haven’t tried using encounter forms, you may find them powerful documentation tools. And if you find the FPM forms useful, you may want to explore the Web sites of the commercial vendors mentioned above. Encounter forms won’t do everything an electronic health record can do, but until you can afford the EHR, they may do everything you need.

About the Author

Robert Edsall is editor-in-chief of Family Practice Management. Author disclosure: nothing to disclose.

Send comments to fpmedit@aafp.org.

 

Copyright © 2006 by the American Academy of Family Physicians.
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