Chronic Condition Documentation
As you pursue PCMH recognition, you will need to pay attention to two aspects of documentation.
1. Ease of documentation for end users.
2. Ease of harvesting documentation to prove achievement of measures for administrators.
To satisfy these two aspects, it is crucial to standardize workflows in the EMR in a way that supports
efficient visit documentation and easy reporting. Standardizing workflows will make visit documentation
faster and simpler, eliminate double-documentation, and ensure that providers receive credit for all the
work they put in toward achieving PCMH recognition.
Consider the following table for recommendations to effectively document chronic conditions.
Measure
3C1
Definition
The care team performs pre-visit
preparations.
Ideal Documentation
For ease of reporting and speed of
documentation, pre-visit preparation
should be documented as an appointment
note or appointment comment on the
schedule.
3D1 and 3D2
Practice reviews and reconciles
medications.
As this is a Meaningful Use (MU)
requirement, most EMRs can capture this
information discretely by clicking a button.
3D5
Practice assesses patient response to
medications and barriers to adherence.
Most EMRs cannot capture this
information discretely. You should
standardize a place in the note for
clinicians to document it that will be easy
for administrators to audit manually.
3D6
Practice documents OTC medications,
herbal therapies, and supplements.
When patients take OTCs, herbals, or
supplements, clinicians can list them
discretely in the patient’s medication list.
To make it easy to identify patients who
ARE NOT taking one of these medications,
your organization should develop a policy
that states patients who DO NOT have an
OTC, herbal, or supplement listed in their
chart and have had their medication list
reconciled are not taking any medications
of that type.
4A3
Practice develops and documents selfmanagement plans and goals.
Some EMRs can capture self-management
goals discretely. For EMRs that cannot,
clinicians should document selfmanagement goals in a standardized
location in the note or in the patient
instructions section of the visit, as
determined by the organization.
3C2
The care team collaborates with the
patient/family to develop and individual
care plan, including treatment goals.
Some EMRs can capture treatment goals
discretely. For EMRs that cannot, clinicians
should document treatment goals in a
standardized location in the note or in the
patient instructions section of the visit, as
determined by the organization.
3C4
The care team assesses and addresses
barriers when patient has not met
treatment goals.
Clinicians should document barriers to
treatment goals in a standardized location
in the note or in the patient instructions
section of the visit, as determined by the
organization.
3C6
The care team identifies patients/families
who might benefit from additional care
management support.
In order to meet this standard, clinicians
should document whether or not patients
would benefit from additional care
management support in a standardized
location in the note as determined by the
organization.
3C3 and 3C5
The care team gives the patient/family a
written plan of care and clinical
summary.
The plan of care should be included as part
of the clinical summary/AVS printed by
your EMR. Because printing clinical
summaries/AVS is a MU requirement, your
EMR should already have a report that
identifies patients who have received one.
4A1
Practice provides education resources or
refers patients to educational resources
to assist in self-management.
For reliability of documentation, it is best
in most EMRs to have clinicians document
in their note that they provided education
resources to patients.
4A2
Practice uses EHR to identify patientspecific education resources.
End-user reporting tools in EMRs are the
best way to identify groups of patients
that could benefit from educational
resources. Practices should run reports to
find patients and show screenshots that
show their method for providing the
information to patients.
4A5
Practice provides self-management tools.
Some EMRs allow end-users to send selfmanagement tools, such as flowsheets, to
patients. For EMRs that do not support
this, clinicians will need to document that
they provided self-management tools to
patients in a standardized location in the
note.
4A6
Practice counsels patients to adopt
healthy behaviors.
Many EMRs allow discrete capturing of
counseling, either via clicking a button or
placing an order for patient instructions.
For EMRs that do not, clinicians should
document counseling provided as part of a
note.