Treatment Forms Internal Medicine EHR

Procedure-Specific Workflows

These forms include procedures and diagnostic tests for 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, and Tilt Table Test. These workflows are designed to lead a provider and/or technician through logical steps in order to document the evaluation and/or narrative capture of all relevant information pertaining to the patient's condition.

Initial Documentation

Document the general Indications For Study along with measurements and findings. Additionally, use the Date Taken and Ordering Physician dialogs to complete documentation.

Indication For Study

The first step in documenting the test or procedure is to select the indication for study. A sub-form will present that lists all pertinent and applicable reasons for the test. This information is also incorporated in the corresponding narrative report for the test.

Ordering Physician

Record the date of the test and the ordering physician for the procedure. This information is conveniently stored on the narrative report.

Measurements

After reviewing the initial test results, enter the applicable measurement information with the PracticeStudio number pad.

Impression Findings

The procedure and diagnostic test forms are designed for you to enter multiple "ranked" impressions. The impressions are reproduced on the narrative report in the order in which they are entered.

Modifiers: You might also select "modifiers" that can be applied to the impression statement(s). These modifiers are used to described or qualify the ending impression. An example of modifiers for an Echocardiogram might be "Mild aortic valve insufficiency."

Locations/Studies: Although different for each of the tests or procedures, the Locations/Studies section of the Impressions form allows you to enter details about your impression.

Indications

These indications are unique to each individual test and procedure, and many of them include sub-forms on which you can further describe the indication. For example, a secondary form might help you to describe "Mild to moderate mitral valve prolapse."

• Not Reviewed
• Denies
• Reports

Plans or Recommendations

Document and record the necessary plans or recommendations for the specific prodecure or follow-up.

Main Treatment Form

The foundation of Chiropractic charting is the main Treatment Form. The most typical examination and treatment options are available from this screen. The design of this form allows you to quickly enter subjective complaints and objective findings, as well as to access adjustments and physical modality treatment options without having to branch off to a large number of additional screens in order to complete your documentation.

Choose from several documentation options to allow for a quick and easy posting process:

• CC/HPI
• Subjective
• Objective
• Assessment
• Adjustment / Activator / Gonstead
• Extremities
• Modaliities
• Lab Orders
• Media
• X-ray

Subjective Entry

Capture the subjective complaint from the patient and provide a detailed desciption with the Subjective Entry.

• The most common complaints, including several buttons for different types of pain description, appear on this screen.
• Anatomical regions are also shown on the same page as the complaint. This provides for immediate and precise documentation of the subjective complaint without branching to any sub-forms. You can, however, access the full array of surface, bone, joint, dermatome, and muscle anatomy forms via the "Anatomy" branch buttons throughout the collection of chart screens.

Objective Findings

The simplified objective finding page tab provides options for documenting the most common day-to-day objective findings. This screen also contains an Anatomy Location section. Some of the common findings on this screen include the following:

• Antalgic Appearance
• Decreased ROM
• Hypertonic Musculature
• Hypotonic Musculature
• Muscle Spasm
• Muscle Tightness
• Muscle Weakness
• Pain with Pressure
• Palpated Misalignment
• Short Leg
• Swelling

Extremities

Record and document extremity manipulation.

Physical Modality

Document the following physical modalities (including Anatomy Location and treatment elements for time and different settings):

• Cold Packs
• Diathermy
• Electrical Stimulation
• Galvanic Current
• Hot Packs
• Infrared Therapy
• Interferential Current
• Joint Mobilization
• Massage
• Mechanical Traction
• Microwave Treatment
• Myofascial Release
• Ultrasound

Adjustment Forms

Select the adjustment type from the following options:

• Standard
• Prone
• Supine
• Extension
• Anterior
• Side Posture
• Posterior to Anterior
• Posterior to Anterior Drop
• Activator
• Gentle

This form, like any form within Chiropractic charting, can easily be customized to suit the specific needs of your clinic; however, with the input of practicing chiropractors, we designed the form to contain the most popular options so that it is usable and intuitive even with no customization.

Gonstead Treatment Form

The Gonstead Treatment form is an additional posting option with the Gonstead Adjustment form providing the following types:

• Sitting
• Prone
• Supine
• Head Drop
• Anterior
• Side Posture
• Knee/Chest
• Posterior to Anterior Drop
• Activator
• Gentle

Activator Treatment Form

The Activator Treatment form is an additional posting option with the Activator Adjustment form providing the following types:

• Clavicle
• Pelvic Deficiency
• Knee and Foot
• Pubic Bone
• Thoracic
• Cervical
• Elbow, Wrist and Hand
• Foot, Ankle and Related
• Hip and Related
• Knee and Related
• Sacrum, Pelvis and Related
• Shoulder and Related
• TMJ/TMD Syndrome

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

PracticeStudio offers 12 gender based graphics along with an additional 13 general graphics for over a total of 3200 possible lesion areas. The sophisticated interface allows for gridlines, hover technology, and area descriptions to allow for the most accurate results.

Type Legends

Each type of lesion is denoted by a special icon to depict a representation of the patient's lesion mark. These will also be saved on the record and review forms.

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.

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.

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.

Procedure-Specific Workflows

Fully customizable, complaint-specific workflow screens form the foundation of Medical charting. PracticeStudio contains approximately 40 different workflows that cover a wide spectrum of complaints and conditions. These workflows are designed to lead a provider and/or nurse through logical steps in order to document the evaluation and/or narrative capture of all relevant information pertaining to the patient's condition.

Body System Layout

Each body system is designed for optimal performance and efficiency. After choosing the desired body systems to review, each body system will present for examination and allow the chief complaint and/or review of systems to be accessed without losing scope for the current exam.

• Exam: the body system in review will always default to the full examination for that system. Within each system, the CC and ROS can be accessed individually as needed.
• Chief Complaint: allows the CC and History of Present Illness to be recorded for the current body system.
• ROS: allows you to branch to the selected body system to enter Review of Systems elements.

CC and HPI

The Constitutional Exam form is the first to display in each of the workflow patterns. This form allows the nurse to enter the patient's vital signs, general condition, and current medications.

• Chief Complaint: The Chief Complaint form lists only those chief complaints that apply to the selected workflow. Once a chief complaint has been selected, the History of Present Illness button automatically enables.
• History of Present Illness: On each workflow-specific CC/HPI form, you can select up to eight categories of information that pertain to the history of the patient's present illness. These categories correlate with E/M coding guidelines to ensure that 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.

Complete HPI Entry

When entering the chief complaint, the HPI can be quickly and easily described at the same time. Each body system is formatted the same way so the learning curve is extremely fast.

The History of Present Illness common categories for each body system include Associated Symptoms, Quality, Severity, Duration, Timin, Context, Modifying Factors, and Location. Each body system may have unique or additional options in addition when applicable.

Procedures

PracticeStudio offers a replete Procedures documentation for providers to efficient record procedures for:

• General (Eye, Foreign Body, Custom, etc.)
• Gastro
• Genitourinary
• Integument
• Musculo

Exam Forms

As previously touched on in the Body System Layout section, the Exam form is the first form that will be displayed for each body system.

• 1: the entire screen is the exam form for the current body system.
• 2: this option immediately navigates to the Chief Complaints and History of Present Illness for the current body system. The exam screen will be automatically reloaded after the CC/HPI.
• 3: this option immediately navigates to the Review of Systems for the current body system. The exam screen will be automatically reloaded after the ROS.

Review of Systems (ROS)

Fully document a patient's medical history and index the workflow complaint or condition. Each body system will have a unique Review of System but each screen will be formatted identically so that the only changes are the pertinent contents for the current body system. The layout consists of :

• Not Reviewed
• Denies
• Reports

Assessment and Plans

Each procedure and diagnostic test has a corresponding narrative report. After you enter test results, findings, impressions, and plans, the report can be printed or faxed to the referring physician. All reports are 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 workflow schematic. A variety of options allow you to complete the patient's encounter.