Visit Overview

Now I'm in a visit within William Hart's chart. You'll notice a new bar has appeared here for the encounter bar showing me who the doctor is, who the provider is that's providing the visit, as well as uh links to go to different sections of the template. It's organized like a soap note, but it is not a soap note.

So I can jump to the subjective section, the objective section, assessment, plan, results, and then we also have a summary as well. These sections have subsections within them and you can just simply jump to them and it's possible to scroll through them or jump. So if you know that you want to go, for example, to visit orders, you can just click on visit orders and it scrolls you to it.

But if you're using this and you're just scrolling through it, you can just use your wheel mouse or your touchpad and scroll through it. Now this is an established patient so a lot of information has been prepopulated like the past medical history, the past procedures, medications, allergies, family history and so forth. And you can see a lot of information is automatically brought in.

This system is turned on with a lot of features, but all of these sections are customizable and can uh be removed. For example, if you're not managing restrictions on patients, you don't have to have that section in your document. If you don't want to mess with linking of documents to your visit, again, you can get rid of it.

And there is an outline editor here that allows you to add or remove sections and then save it as a template so that you can get to your template very quickly later. Another feature of this encounter bar is the ability to stage encounters into different stages. So, for example, intake can be completed by intake personnel at the front desk.

Nursing can complete parts of it, then the provider, and then depart or checkout. And this allows you to set the stage of the encounter and it tracks how long each stage takes during the visit. So let me quickly document a visit.

The first section is the chief complaint and it allows you to bring over and or see the chief complaint from a prior visit. Normally we would bring this information over from a appointment but the nurse can capture this or free text. As you can see, we actually have built-in dictation into the system.

So, it can capture voice files or it does support voice recognition as well. I'll just enter backstrain as the complaint for today. The system also has the ability to recognize based on the chief complaint a possible protocol to run.

And as you can see here, I have many protocols to choose from. And each protocol customizes the rest of the encounter, the different questions in each of the sections. So, for example, if I choose occupational injury here and click next to go to the next section, we'll be presented with a history of present illness that is specific to an occupational injury.

As you can see, the past medical history came forward, past procedures, preventative care, presenting medications, allergies and tolerances, family history, the immunization, social history, as well as all of the questions required for meaningful use. Here's a review of systems that automatically gets populated and we have macros for bringing over common statements. It is possible to configure an all normal and then to chart by exception and whatever sections are completed are the ones that are added.

Only the sections that were added are displayed. There's an area to enter vitals and we have direct interfaces with Welch Allen and other vitals monitors. And there are alerts for example that pop up and can automatically enter orders.

So the BMI is high and weight control education is needed. Continue to mark the patient education given and order a dietary consult. If we hit okay, it'll add an order automatically for a dietary consult in the plan.

And you can see it calculated BMI automatically. At the bottom here there are the historical height and weight of the patient. Next becomes physical exam.

It has the same capabilities that the reviewer systems had showing past previous values for the physical exam that have been collected in a prior physical exam and they can be brought over. Tests and procedures can be conducted in the system and automatically items that are on the patient's due list that were ordered appear here until they're completed. So for example, if a CBC was on the list, you can simply add it and it automatically adds the CBC to the visit and then results could be entered in.

When procedures are marked complete, automatically charges can be added to the billing section. Next, we'll have the assessment, which is systems and diagnosis. And this brings up the problem list automatically.

It's configurable as to whether or not problems that are on the problem list automatically apply to today's visit. In this case, it does not. So I can come in here and indicate problems that are active and may contribute to today's visit.

It's possible as well to enter in new problems through the autocomplete or through a pick list. Next comes clinical guidelines which are based on the medications and the conditions of the patients as well as guidelines. So for example, I can see that patients should be on deoxin for congestive heart failure and then come in and write a prescription.

We get a drug interaction that can be dismissed for all patients or for just this patient and the different kinds of dismissals so that you're not bothered by alert fatigue. There are different kinds of visit orders and templates for them with pick list. So for example, I can make an imaging order and there are pick lists that are configurable where you can actually even modify these and change them to your own liking or here in the autocomplete search for orders automatically.

We collect billing and charges automatically. There is an automatic ENM code that can be calculated depending on the level of documentation and that can be changed automatically. And there is a calculator here that allows you to override assumptions made by the calculator and see what the resultant code looks like.

There is a pick list for entering charges as well if procedures are done in the office along with the ability to collect a modifier as well. These automatically flow over to the billing system. There is a place here to generate referral notes to referring providers as well as carbon copies that go to the patient and the ability to carbon copy other physicians as well.

And then a summary is produced of all the information with the changes that have been made as of today's visit. So you can see Dejoxin was added to the final medications that the patient's going home with. When the notes complete, you can just complete the note and it produces documentation automatically.

The drug interactions here can be hidden, but this is an example of what the note would look like for the visit along with additional views for referring physicians. And finally, the ability to push this information to a patient in no more clipboard or to be able to print it.