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A teacher planning book is enough for complete hospital visit notes

It’s worked for years. It costs less than $10. And with it, practice manager Patricia Russell has never missed posting a single hospital or nursing home visit.

It’s a teacher’s daily plan book. And for any physician who doesn’t use a digital device for note taking, it’s the perfect solution for documenting out-of-office visits, says Russell who manages the internal medicine practice of George. R. Cox, MD, in Suffern, NY.

The books, which come from office supply stores, are spiral bound and have Monday-through-Friday columns plus an empty column that can be used for weekend visits. The columns go down the length of the page, so there’s space enough for complete visit notes.

The office’s procedure is simple. The doctor takes it to the hospital and nursing home each morning and in the day’s column writes down the usual – patient name, diagnosis, and status.

He also notes when a patient is admitted, and if he doesn’t bring back the admission sheet, Russell can access it on the hospital’s system. When he covers for another physician, he writes in that doctor’s name with the patient note, and that data too is accessible via the hospital computer.

The books were a necessity, Russell says. When she started with the practice, the doctor – like most physicians at the time – was documenting out-of-office visits “on little tiny pieces of paper that he kept in his pockets” and then dropped them on her desk, and she “had to make sense of them.”

Now he gives her one book instead of a dozen notes, and she posts the visits and puts the book on his desk for the next morning.

The daily posting takes organization, “but it’s something that had to be built into the day’s schedule” to keep the posting current, Russell says.

The book would work for any size office, according to Russell, who points out that it’s especially helpful for physicians who have been in practice a long time and still rely on pen and paper.

It makes it possible to capture all the information that’s entered in a computer. It also makes it easy for anybody – doctor or staffer – to check back on any visit without having to look at the computer or the record.

Because they are for teachers, the books cover only 180 days. But that’s not an issue, Russell says. She simply replaces them when they are filled and labels the start and end dates on the outside. The office retains the books for about five years.

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