Charting Internal Medicine EHR

Initial Review/Entry

The Nurse Entry button on the Homebase presents all necessary screens for entry of Constitutional, PFSH, and Medication information. For established patients, the nurse enters this information and also has the ability to review and comment on the most recent plans and assessments prior to standard entry.

Cardiology Procedures

Entering Diagnostic and Treatment Procedures with accompanying Referral reports is fast and easy with the Cardiology-specific procedure screens and reports. Entry screens for the most widely used diagnostic tests and procedures are already in place and ready for use with the charting screens. These screens and reports include the following:

• Carotid Ultrasound
• Echocardiogram
• Electrocardiogram
• 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

Complete Standard Adjustment, Activator, and Gonstead SOAP Screens

For those providers that do Activator and/or Gonstead, there are complete all-in-one SOAP screens for these methods as well! Just like the standard adjustment SOAP Screen, there are all-in-one screens for Activator SOAP and Gonstead SOAP that allow for the entry of CC/HPI, Subjective, Objective, Assessment, Activator, Activator+, Gonstead Adjustment, Extremities, Modalities, Lab Orders, Media, and X-Rays from a single screen.

Treatment and SOAP Notes

The Chiropractic Data Set is designed to make chart entry fast and efficient. We know that there are many different ways to practice, and we try and meet each of those needs. For example, the all-in-one S.O.A.P. screen for the standard treatment as well as the Gonstead and Activator treatment allows the provider to document almost the entire encounter from a single location.

Simple Meds

PracticeStudio offers a simple allergy and medication charting environment to track your patient's drugs and allergies.

New Lesion Screens

PracticeStudio's Dermatology solution provides new updated lesion screens made for easy printing, customization, and over 3200 lesion areas for precision. The interactive program also has a complete list of skin disorders with detailed options of marking location. These clean-cut screen shots can modified with our own Media editor and saved on the encounter review form.

Body System Charting

The Body System Selection allows all of the desired body systems to review to be selected from a single location and loaded into the encounter workflow. Each Body System will allow for the entry of the following:

• Chief Complaints
• History of Present Illness
• Examination
• Review of System
• Custom or unique content specific to each body system

Medical WorkFlows

When treating specific problems, you can access one of the many predesigned workflows that logically present input screens in the order in which you want to document your patient's condition. Standard workflows include the following:

• General (Anxiety, Diabetes, Eye Problems, Obesity, Pediatric Illness, Thyroid Disease, etc)
• Cardiovascular
• Respiratory
• ENMT
• Gastrointestinal
• Genitourinary / Breast / Obstrtrical
• Musculoskeletal
• Neurological
• Or create your own custom workflow and choose from thousands of pre-designed screens

RX Writer (e-Prescription)

PracticeStudio's RX Writer is a Surescripts certified electronic prescription wizard complete with allergies, prescriptions, medications, and medication history. Take control of your patient's medication requests with the easy navigation and robust services of the PraticeStudio RX Writer.

Media and Documents

You can use existing screens, take photos, or even use your web cam for videos with our modern Document and Media editor. Choose from several options to edit, crop, rotate, add text, draw, and more with your custom images. After customizing your pictures the way you want you can save them to your Patient media file and even attach them to your encounter review forms.

Customizable Chart Screens

PracticeStudio chart screen sets come with comprehensive screens that are ready to use, day one. Our discipline-specific screens have been continually improved over the past 20 years with direction from practicing healthcare providers and contain an extensive set of features that facilitate fast and efficient chart note entry.

Ready for Use

One of the greatest strengths of PracticeStudio EHR is that the system is installed with thousands of prebuilt screens, ready to use right out of the box. Many competitive systems require days, weeks, or even months of "training" in order for the system to be usable and in the end the competitive system still may not create the desired note.

Complete Encounter Review

Reviewing the encounter in an editable narrative format is extremely easy and is accessible at any time. Here are just a few things you can do within an Encounter Review:

• View all encounter content
• Review problems list
• Edit any narrative text in place
• Choose any text and have it navigate back to the screen from which it was entered
• Apply a status to any text (i.e. improved, worsened, etc.)
• Export review to PDF

Easy Navigation and Search Tools

Quickly search through encounters, patients, notes, and many more with the PracticeStudio navigational wizards. These custom designed browsers allow for users to access information

Chronograph

PracticeStudio offers the unique Chronograph which allows the user to observe patient's data over time. Any piece of data in the system that captures numerical data such as range of motion, temperature, weight, height, lab result values, pain scales, etc. will automatically appear within this list. When a value falls above or below a normal, an arrow will be shown as an indicator to that affect.

Finally, you can graph all points of data and graphically see that data displayed over time. In scenarios where there are multiple parts to the value such as blood pressure, the normals as well as the points are plotted uniquely on the same graph to easy viewing.