At the heart of the cardiology data set lies the procedure specific workflow forms. As previously mentioned, these forms include procedures and diagnostic test for Carotid Ultrasound, Echocardiogram, Electrocardiogram, Electrophysiology Study, Exercise Stress Test, Holter Monitor, Invasive Procedures (i.e. Catheterizations), Leg Arterial Study, Leg Venous Study, Nuclear Medicine, Pacemaker Implantation, Renal Artery Ultrasound, Stress Test, and Tilt Table Test. The forms are arranged for maximum speed of input while maintaining the depth of information required for proper documentation.
Indications For Study: The first step in documentation of the test / procedure is selection of the indication for study. A sub-form will be presented listing all pertinent and applicable reasons for the test. This information will also be incorporated in the corresponding narrative report for the test.
Ordering Physician: Secondly, the date of the test and the ordering physician will be noted for the procedure. Again, this information will be highlighted on the narrative report.
Testing Detail: Depending on the test or procedure, measurement information may next be entered. In many scenarios, the information entered up to this point is performed by the technician. For example, in the case of an echocardiogram, the technician will conduct the test and enter the pertinent information. The cardiologist will then review the initial test results and produce the evaluation for the patient.
Echocardiogram Procedure Form
In a typical scenario, the cardiologist will finalize the procedure or diagnostic test after the technician has entered the results. Using the Echocardiogram procedure as an example, the physician would first review the entries made by the technician and then proceed with entry of the findings and impressions for the test.
Impressions: The procedure and diagnostic test forms are designed for the physician to enter multiple "ranked" impressions. The impressions will be reproduced on the narrative report in the order in which they are entered.
Modifiers: Secondly, the physician may select "modifiers" that may be applied to the impression statement. These modifiers are used to described or qualify the ending impression. An example for an Echocardiogram may be "Mild aortic valve insufficiency."/p>
Locations / Studies: Although different for each of the tests or procedures, the Locations / Studies section of the impression form provides the detail for the impression.
Indications: The final step when completing an impression is to select the indication associated with the area and modifier. These indications are unique to each of the individual tests or procedures.
Many of these indications have sub-forms to further describe the indication. For example, a secondary form may help the cardiologist describe "Mild to moderate mitral valve prolapse."
Narrative Report
Each procedure and diagnostic test has a corresponding narrative report. After entry of the test results, findings, impressions, and plans, the report may be printed or faxed to the referring physician. All reports will be saved for future reference and historical purposes. Several of the report templates offer both an expanded and a “short” format. The latter restricts the heading and margin size in order to present more information in a shorter format.
Overview |
Procedures & Tests |
Patient Walk-Through |
Narrative Reports |
EMR Add-Ons
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