Patient Walk-Through Internal Medicine EHR

Patient Registration

Let the front desk employees capture the essentials such as name, date of birth, gender, address, phone number, etc. Once a patient record has been created, multiple users can access the account simultaneously (e.g. one user might want to enter more detailed patient information and another user might want to enter insurance information on a different workstation).

Check-In

Checking in the patient affords several options:

• Immediately see any balances due, current insurance information, and verify the patient insurance online or manually.
• The patient will not appear on No-Show reports and eliminates no-show-related insurance issues.
• A routing slip can be printed for the patient that can help the process through the clinic.
• Additionally, once checked-in the patient-tracking feature will be enabled to allow users to track the patient's progress through the clinic.

Insurance Information

Ensure that the patient's insurance information is current and on file to ensure easy billing.

Online Insurance Verification

From anywhere in the system the patient's insurance can quickly and easily be verified online. Anyplace that the patient code control exists, there is a button on the right with a shield that will show the current insurance information. At the same time, the insurance can be verified online or manually. This can greatly reduce the stress and energy on the staff to ensure valid and active plans while also improving the time and amount paid by the carriers.

Chief Complaint and History of Present Illness (CC and HPI)

Document the Chief Complaint and record the History of Present Illness with easy quick touch buttons.

• All easy touch/click buttons produce the necessary narrative text and records the discrete data elements
• Choose a Chief Complaint from our replete database with hundreds of configured categories.
• Document the History of Present Illness with additional indexes including location, quality, severity, duration, timing, context, modifying factors, and associated symptoms.

Past, Family, Social History (PSFH)

Record all aspects of Past, Family, and Social History. A full complement of screens for recording any illnesses, surgeries, injuries, and/or prior treatments is included in this section. The section also includes a set of detailed screens that permit exhaustive entry of information pertaining to automobile accidents.

Review of Systems(ROS)

The Review of Systems screen-set provides an individual anatomical region which allow the reporting or denial of symptoms in all pertinent systems (particularly the Musculoskeletal and Neurological systems). Each form includes a "Denies All" button, which quickly documents E/M coding requirements while allowing the CA to enter pertinent positive symptoms.

Constitutional Exam

This form includes general information such as Height, Weight, Blood Pressure, Pulse, Respiration, and General Appearance. As the information is entered, all E/M Coding bullets are being recorded.

Review and Initial Evaluation

The main charting review screen provides the following tools:

• Patient Summary contains the patient's EHR information, patient photo, insurance verification, and the patient's current and previous encounters.
• Encounter Summary contains the ecounter's date and time stamp and options to review, print, or maintain previous encounters.
• Posting Options create new encounters, create new encounters from a previous date, or modify previous encounters. Additionally, you can select the appropriate provider and specialty database.
• RxWriter Go straight to the PracticeStudio online prescription wizard for easy scripting.
• Review and Search features provides a quick and easy look into all the previous encounters and search tools to find records quickly.
• Media and Labs See the latest labs or review the patient's media files
• Care Documents Create, view, import, or export Care Documents right from the main menu with customized dialogs for enhanced features.
• Chronograph PracticeStudio EHR's ChronoGraph® feature can graph any numerical data: the data can be formatted at run-time to appear in line graphs, bar graphs, or pie charts. This is especially useful for tracking any numerical data (i.e. ROM, Pain Levels, Weight, Height, etc.) over the course of a patient's treatment.

Treatment

PracticeStudio offers several replete workflows for each specialty along with and interactive online prescription wizard to quickly send scripts.

• Procedures: Customize your own workflows or use the prebuilt workflows which offers several options including:
  • Carotid Ultrasound
  • Echocardiogram
  • Electrocardiogram
  • Electrophysiology Study
  • Exercise Stress Test
  • Holter Monitor
  • Invasive Procedures (e.g. Catheterizations)
  • Leg Arterial Study
  • Leg Venous Study
  • Nuclear Medicine
  • Pacemaker Implantation
  • Renal Artery Ultrasound
  • Stress Test
  • Tilt Table Test
• RxWriter At any time, you can open RxWriter, which is capable of eprescribing (or faxing or printing scripts), medication history download, and formulary and benefits checking. RxWriter is Surescripts® certified for Prescription Benefit, Prescription History, and Prescription Routing and provides you with all the required tools for creating and maintaining your patients' prescriptions. The drug database contains over 50,000 drugs.
• Interactions RxWriter also performs multiple screening tests (drug-drug, drug-allergy, drug-alcohol/food, duplicate therapy, drug disease, and dosage). These screening tests are performed during the prescription process and (optionally) after a new allergy or adverse reaction is added to the patient's record. The results from previously run screenings can be viewed at any time.

Treatment

Examination and treatment, including adjustments and physical modalities, are handled on specialized forms:

• Pain Disability Ratings: The Pain Disability screen allows users to measure disability based on one of the following methods:
  • Oswestry
  • Vernon-Mior
  • Roland-Morris
  • General Pain
  • Modified Zung
  • Modified Somatic
• Review: After, inputing the pain disability ratings users can review and graph the value using the PracticeStudio ChronoGraph.
• Supplies Entry: Patient supplies (e.g. vitamins, orthotics, pillows) can be attached to a corresponding CPT code that supply automatic updates in the PracticeStudio Inventory Tracking system and individual supply items that have specific instructions can be printed at patient check-out.

Treatment

Examination and treatment of lesions are handled on specialized forms:

• Procedures: You can customize your own procedure workflows or use prebuilt workflows in the data set, which include the following:
  • Accutane
  • Acne
  • Chemical Peels
  • Consultation
  • General Injection
  • Intense Pulsed Light
  • IPL Follow-Up
  • Laser
  • Melanoma
  • Mohs Pre-Op
  • Op-Notes
  • Post-Op Notes
  • Rosacea
  • Sclerotherapy
  • Warts
• RxWriter: At any time, you can open RxWriter, which is capable of eprescribing (or faxing or printing scripts), medication history download, and formulary and benefits checking. RxWriter is Surescripts® certified for Prescription Benefit, Prescription History, and Prescription Routing and provides you with all the required tools for creating and maintaining your patients' prescriptions. The drug database contains over 50,000 drugs.
• Interactions: RxWriter also performs multiple screening tests (drug-drug, drug-allergy, drug-alcohol/food, duplicate therapy, drug disease, and dosage). These screening tests are performed during the prescription process and (optionally) after a new allergy or adverse reaction is added to the patient's record. The results from previously run screenings can be viewed at any time.

Treatment

Specific procedures can be documented using custom procedure workflows.

• Procedures: You can customize your own procedure workflows or use prebuilt workflows in the data set, which include the following:
  • Aspiration
  • Burn
  • Casting
  • Colposcopy
  • Culture and Sensitivity
  • Diaphragm Fitting
  • Dressing
  • Ear Cleaning
  • Endocervical Curettage
  • Endocervical Polyp Removal
  • Endometrial Biopsy
  • Foreign Body Removal
  • Graft of Skin
  • Immunizations
  • Incision and Drainage - Abscess
  • Incision and Drainage - Thrombosed Hemorrhoid
  • Injection - Trigger Point
  • Injections
  • IUD Insertion
  • IUD Removal
  • Knee Joint Fluid Replacement Therapy
  • Laceration Treatment
  • Loop Electrosurgical Excision Procedure (LEEP)
  • Manipulation of Rib
  • Pain Management
  • Nail Disorder Treatment
  • Pessary Fitting
  • Scope Treatment
  • Skin Lesion Treatment
  • Splint Application
  • Suture Removal
  • SynchroMed Refill
  • Vasectomy
  • Vulvar Biopsy
• RxWriter: At any time, you can open RxWriter, which is capable of eprescribing (or faxing or printing scripts), medication history download, and formulary and benefits checking. RxWriter is Surescripts® certified for Prescription Benefit, Prescription History, and Prescription Routing and provides you with all the required tools for creating and maintaining your patients' prescriptions. The drug database contains over 50,000 drugs.
• Interactions: RxWriter also performs multiple screening tests (drug-drug, drug-allergy, drug-alcohol/food, duplicate therapy, drug disease, and dosage). These screening tests are performed during the prescription process and (optionally) after a new allergy or adverse reaction is added to the patient's record. The results from previously run screenings can be viewed at any time.

Assessment

Assess the problems and provide a diagnosis:

• Assessment Form: The Assessment form displays a patient's problem list, which shows any chief complaints or diagnosis codes that have been entered during the encounter. You can choose to remove or add items to the problem list during encounter posting. Notations pertaining to the patient's prognosis and any follow-up visit information are also entered at this time.
• Patient Education: PracticeStudio offers an online patient education database through Medline Plus. Additionally, users can create their own articles to display for patients.
• Excuses: create permission slips/excuses: the data set includes Authorization for Absence, Return to Duties (with or without restrictions), and Care Certificate forms. And not only are excuses printed for the patient; they are also noted in the patient's chart.
• Lab Orders: PracticeStudio's Lab Management system allows automatic transmittal of lab orders to different labs around the country via industry-standard HL7 exchange. (With a bi-directional interface, users can see orders as soon as they arrive.
• Charge and Diagnosis Posting: Since PracticeStudio is a comprehensive Electronic Health Record (EHR), CPT and Diagnosis notations made during chart entry can automatically be updated to the PracticeStudio billing system, which not only speeds posting but also prevents most posting errors.

Wrapping Up The Patient Visit

There are multiple things that need to happen when wrapping things up with the patient depending on how your clinic operates:

• Messages and Notifications to Checkout: PracticeStudio helps the front office operate in sync with everything going on in the treatment rooms. The provider can even provide customized instructions as to what needs to be done while checking out the patient, literature to give, etc.
• Future Appointment Scheduling: As a seamless part of the checkout, the provider can schedule a future appointment themself or send a notification to the front desk telling them to come back in 2 days, 2 weeks, etc.
• Excuses, Scripts, Notes: Many times a process will have already taken place such as a permission slip being printed out or a script sent to the pharmacy electronically. In any case, the checkout process will remind the front office staff to either give the patient the slip sitting on the printer or that the pharmacy already has verified that the script has been received and will be ready when they get there.
• Finalizing Encounters: PracticeStudio has the ability to finalize encounters automatically or manually through several different processes. If the preferred method is to manually finalize an encounter after being reviewed, this process can take place here or later in the day by reviewing all encounters at once. Most times providers elect to have the encounters automatically finalized since a finalized encounter can still be modified as all changes are audited.