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PracticeStudio's Urgent Care chart screens provide simple an elegant procedure-specific workflow forms.
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.
Document the general Indications For Study along with measurements and findings. Additionally,
use the Date Taken and Ordering Physician dialogs to complete documentation.
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.
Record the date of the test and the ordering physician for the procedure. This information is conveniently stored on the narrative report.
After reviewing the initial test results, enter the applicable measurement information with the PracticeStudio number pad.
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.
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."
Document and record the necessary plans or recommendations for the specific prodecure or follow-up.
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:
Capture the subjective complaint from the patient and provide a detailed desciption with the Subjective Entry.
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:
Record and document extremity manipulation.
Document the following physical modalities (including Anatomy Location and treatment elements for time and different settings):
Select the adjustment type from the following options:
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.
The Gonstead Treatment form is an additional posting option with the Gonstead Adjustment form providing the
The Activator Treatment form is an additional posting option with the Activator Adjustment form providing the
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.
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.
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.
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.
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.
All of the standard treatment options for lesions reside on the Lesion Treatment Form:
Returned diagnostic results can be entered on the Pathology Form:
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.
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.
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.
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.
PracticeStudio offers a replete Procedures documentation for providers to efficient record procedures for:
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.
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 :
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
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