Medical record-keeping terminology survey

Let’s say you have a paper medical record, or “Chart”. You have a demographics section etc…

In this medical record, you have all the interventions in a chronological order. These services are billable, and fairly complex in structure. You also have a list of short annotations where there was a patient communication, an important notation about the patient, or remarks about missing appointments et cetera that is a permanent part of the medical record. Typically, this is a piece of lined paper with a narrative section, a chops box for signing, and a date/time box.

QUESTION:   There is a title at the top of this paper.  What is the title?

What’s your question ?

I’m trying to describe something, and get people to tell me what they think it should be called, without using/suggesting any names. It is a matter of contention, and completely neutral party clinical opinions are desired. Rephrasing question: General statements recorded in a patient chart that are not related to a specific procedure are called what?

“General Observations” or may be “Visit Notes”?

They are not related to a visit (i.e. encounter or date of service). It is also not necessarily an observation. An example requiring such is something that might already be noted elsewhere in structured data, say a missed appointment, but requires additional documentation: "Patient called and cancelled appointment today. Reports; “too sick to drive since my last medication change”.

Some people can use ‘Phone Records’ . Also can be ‘Miscellaneous’ or ‘Patient reported events’

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I would agree to all of those, and those, within this system should be “tags”, but I think Chart Remarks has a lot of potential to be what we are looking for.

Let me stop being coy, so we can test that assumption. The question was should they, as a general category/form name be referred to as “Chart Notes”, “Patient Notes”, “Chart Addenda”, “Chart Remarks”, or something else? Chart Notes and Patient notes are thought to be too general and perhaps confusing to some people, as sometimes what you could call “Visit Forms” or “Encounter Forms” might be equated to “Chart Note”, even if they are presented next to each other in a menu. The issue is that for a simple remark too many users create an “Encounter” record, which has a date of service, facility and a number of other things attached to it, and is seen as a viable billable date of service by the practice management side of things. When incidental notes are added as an Encounter, it kind of junks things up for the billing office. From the clinical side, it is just as bad, because that is not appropriate documentation. To push the users in a useful direction, we hope to provide an easy and more visible way to add permanent notes to the patient record without using the structure an “Encounter” brings with it. The name is very very important, as we need folks to intuitively grasp the difference.

@EHR developers: What do you think about Chart Remarks? I think that may be it. Far better than Chart Note or addenda I think. This suggestion was just made by a Hack Shack Member here…