At the core of PracticeStudio's Dermatology chart screens lie the procedure-specific workflow forms.

Main Lesion Form

The foundation of Dermatology charting is the main Lesion Form. The most typical examination and treatment options are available from this screen, which contains options for graphic-based documentation, text-only documentation, treatment entry, and pathology. The design of this form allows you to enter examination findings and access treatment options without having to branch off to a large number of additional screens in order to complete your documentation.

Anatomy Markup Forms

The Anatomy Markup Forms offer a variety of graphics for each gender and many of the major anatomical regions. Anatomy markup forms supplement the main Lesion Form by providing the capability of designating the exact location of each lesion.

Graphics

The graphic that displays depends upon the gender of the patient and the area you select from the main Lesion Form. Graphics include, but are not limited to, the following:

• Ears
• Entire body
• Face
• Hands
• Nose
• Top of the head

Problem Entry

Options available on Anatomy Markup Forms provide for the documentation of 18 unique, trackable lesions in virtually any body system. PracticeStudio captures the size, type, and location of lesions as you document them.

• Type and Diagnosis: Select the type of lesion, and PracticeStudio automatically assigns the corresponding diagnosis code when saving the lesion to the patient's record.
• Location: Choose from all major anatomical regions and specify the exact location of each lesion by simply selecting the corresponding location on the graphic.
• Size: Enter a specific size or a size range. If entering information pertaining to multiple lesions, you can describe any number of different lesions with different sizes.

Type Legend

As each type of lesion is selected, a corresponding symbol appears on the anatomy graphic wherever you touch the screen or click the mouse.

Graphic Storage

When you complete the form, the graphic portion of the screen is captured and stored as an image in the patient's electronic medical record. The image includes all of the lesion markups you placed on the graphic, as well as the Type Legend explaining what type of lesion each symbol represents. When a narrative report is printed for the patient, these stored electronic images are inserted into the body of the report and printed.

Lesion Treatment Form

All of the standard treatment options for lesions reside on the Lesion Treatment Form:

• Lesion Number: Select the lesion for which you are entering treatment information. The number corresponds to the lesion number entered when you documented the problem on the Anatomy Markup Form.
• Lesion Description: As soon as you select a lesion number, the description of that lesion is automatically retrieved from the PracticeStudio record.
• Type of Treatment: Select the type of treatment (e.g. liquid nitrogen) for the lesion.
• Treatment Notes: Add additional notes (e.g. patient handouts, post-op instructions, anesthesia notes) to the treatment portion of the narrative.
• Treatment Totals: Review treatment options and calculate all lesions documented, subtotaled by lesion type category. This information is saved in the patient's chart and can be used to help select the appropriate billing level for the procedures.

...one of my favorite aspects of the system is the lesions screen. While in this particular screen, I am able to document which lesion I am describing, the lesion's size, type, and location, while the system automatically counts and documents each type of lesion identified. The same screen is used to document the method of treatment used on each lesion. This feature has dramatically increased the speed and accuracy with which I can document lesions during an exam. As I enter the data, it is all captured in the EMR, so I never have to dictate.

Pathology Form

Returned diagnostic results can be entered on the Pathology Form:

• Lesion Number: Select the lesion for which you are entering pathology results. The number corresponds to the lesion number entered when you documented the problem on the Anatomy Markup Form.
• Pathology: Choose diagnostic results that correspond to the pathology lab's analysis.
• Modifiers: Select additional descriptors 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, enter the date of the pathology report using either the calendar or date entry buttons and enter your initials.