Anatomy Markup Form

Graphics: Depending on the gender of the patient and the area selected from the main lesion form, the appropriate graphic will display from a complement of screens including: hands, nose, ears, face, top of head, and body.

Graphic Storage: After completion of the form, the graphic portion of the screen will be captured and stored as an image in the patient’s electronic medical record. This image will include all of the lesion “markups” or “drops” that have occurred. When printing the narrative reports for the patient, these images will be inserted and printed within the body of the report.

Problem Entry: The options available on this page tab permit the entry of 18 unique, trackable lesions in virtually any body system. As the lesions are entered, the size, type, and location are noted.

Type and Diagnosis: One of the first aspects in lesion entry, is selecting the type of lesion found. The Red Dot on the type buttons indicates that the diagnosis code will be automatically assigned as the lesion type is selected. This speeds input and eliminates steps.

Location: The lesion form is designed to have all major anatomy locations listed on the same form. Again, this design increases the throughput of documentation in a busy practice.

Size: The size buttons provide entry for the lesion dimensions. A specific size or size range may be entered. If entering information pertaining to multiple lesions, the number button permits the doctor to describe any number of different lesions with different sizes.

Lesion Treatment Form

Lesion Number: When creating narrative for lesion treatment, the first step in the process is touching the lesion number. These numbers correspond to the lesion numbers entered during problem notation.

Lesion Description: Once the lesion number is selected, the description of the lesion is automatically pulled forward from the matching lesion problem entry.

Type of Treatment: The treatment page also contains the type of treatment that is being used for the corresponding lesions.

Treatment Notes: Additional notes such as patient handouts, post-op instructions, anesthesia notes, and patient consent forms may be added to the treatment portion of the narrative.

Treatment Totals: After all lesion treatment is finalized, the Treatment Totals button may be clicked to calculate all of the lesions that were treated, sub-totalled by category of lesion type. This information is captured in the chart note for the patient and can be used to help select the appropriate billing level for the procedures.

Pathology Form

Lesion Number: When creating a narrative for pathology results, the first step in the process is touching the lesion number. These numbers correspond to the lesion numbers entered during problem notation.

Pathology: This section allows for the selection of the diagnostic results of the pathology laboratory analysis.

Modifiers: Additional descriptor buttons may be selected from this section to further define special characteristics of the diagnosis.

Date and Initials: Once all the pathology results have been entered for one or more lesion problems, the date of the pathology report can be entered with either the calendar or date entry buttons. The initials button allows the entry of the initials of the individual that recorded pathology results.