Treatment Forms Internal Medicine EHR

PracticeStudio's Internal Medicine chart screens provide simple an elegant procedure-specific workflow forms.

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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.

Charting
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Charting

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.
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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.
Charting
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Charting

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.

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Procedures

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

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

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.
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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
Charting
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Charting

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.

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