CC and HPI
At the heart of the medical data set lies the complaint specific work flow forms. There are approximately forty different work flows that cover a wide spectrum of complaints and conditions. The inherent design leads the doctor and nurse through logical steps in the evaluation and narrative capture of all relevant information pertaining to the patient’s condition. The Constitutional Exam form is the first form displayed in any work flow pattern. This allows the nurse to enter the vital signs, general condition, and the current medications list for the patient.
CC and HPI Form: Each work flow has an individualized chief complaint and history of present illness form. This concept helps speed input of complaint specific information.
Chief Complaint: Only the narrow range of chief complaints that apply to the work flow are listed. Upon selection, the History of Present Illness button for that complaint is automatically selected.
HPI: Up to eight categories of information that pertain to the history of present illness are available on each of the work flow specific CC/HPI forms. These categories correlate with the E/M coding guidelines to ensure that the proper documentation levels are met. The most common history elements are shown on the form, with branches to sub-forms only as more detail is required. This functionality speeds input while allowing for all documentation possibilities.
Additional Complaints: If the need arises, the “Other Chief Complaints” button will branch to an index form where any other chief complaint may be entered. The index form allows selection by body system or by other work flows. One exciting feature of the work flows is this ability to “branch” to other complaints and areas of documentation and then have the system automatically return to the originating branch form. This allows the doctor or nurse to enter the information when needed; thus, greatly enhancing the narrative input experience.
Complete HPI Entry: If greater detail of documentation is required for the history of present illness, then category branches are available during the HPI entry session. These branches will navigate to the individual body systems for a plethora of HPI entry options.
Exam and ROS
The Past, Family, and Social History form follows the CC/HPI specific form for the work flow. This is a common form set where all of the PFSH data is input. The work flows are designed to display forms in the logical sequence of events; thus, this form follows after the chief complaint is entered and described.
Exam & ROS Index: The fourth form in the work flow series is the Exam and Review of Systems form. Each work flow has specific index forms that list pertinent body systems for the work flow complaint or condition.
Body System Layout: As mentioned, each of the index forms contains all pertinent body systems for the specified work flow complaint. Each of the body system elements contains four distinct buttons for entry of narrative data. When touched, the “Normal” button will post narrative text for the represented body system that indicates an exam was performed for that body system and all findings were “normal”. The “Exam” button will allow the doctor to branch to the selected body system to enter full exam findings. The “Denies All” button will indicate that the patient denied all abnormals in a Review of System for the respective body system. “ROS” will allow the doctor to branch to the selected body system to enter review of system elements.
Automated Selections: The row of buttons at the bottom of the form allows the doctor to perform several automated functions. The “Selected Norm Exam” button will automatically pick the “Normal” buttons for the body systems on the form. The “Selected Denies ROS” button will post normals for the form’s Review Of Systems buttons. “All Norm Exam” will post a normal exam for all body systems, not just the pertinent exams. “All Denies ROS” does the same for the Review Of Systems. The “Pertinent Exam/ROS” button will automatically queue all of the pertinent Exam and ROS forms to be displayed in sequential order.
Assessment and Plans
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. The Assessment Form is the final form in the work flow schematic. A variety of options allow the doctor to complete the encounter for the patient.
Item Selection: The first step allows the doctor to select a complaint to document. This list will contain chief complaints, previous diagnosis, or any discrete narrative data “marked” by the doctor as a problem.
Assessment: Applicable general assessment comments will be applied to the complaint. More detailed assessment statements are available on subsequent forms.
Plans: Continuing treatment plans are then noted by the doctor. These plans may include detailed notes about the patient’s status, response to care, improvement, and release from care. Return visit information is also documented.
Ancillary Notes: Depending on the status of the patient and the doctor’s method of practice, many additional functions may be performed to complete the patient encounter. One function is to establish a diagnosis code for the patient. Another is to review the E/M level of service billing based on the current narrative data, and then select the appropriate CPT code to be updated to the billing segment of PracticeStudio®. Other features that are available include selection of Patient Education articles, Excuses, Lab Orders, and selection of referring doctors. Finally, any medication changes or additions may be posted to the RxWriter portion of PracticeStudio®.
Overview |
Work Flows |
Patient Walk-Through |
Narrative Reports |
EMR Add-Ons
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