Patient Evaluation Worksheets

Patient visit notes are generally created by assembling one or more diagnostic or therapeutic worksheets. A listing of the currently available diagnostic and therapeutic worksheets include:

Clinical Worksheets

Clinical Note (complete)

Includes sections for HPI, PMHx, Intervention Hx, Device List, Medication List, Allergy List, Family Hx, Social Hx, Physical Ex, Systems Review, Cardiac Risk Factors, ECG, Other testing results and Assessment & Plan. In each section the user has the option of using a specialized worksheet, pasting in preformed text, using text and data from previous encounters or entering the data manually.
The management plan of Medical/Surgical Problems can be followed using the Problem-Tracking® feature.
The E & M Coding Calculator® insures the highest-level billing codes are used for all patient encounters while electronically documenting that Medicare documentation guidelines have been followed.

Clinical Note (follow-up)

The management plan of Medical/Surgical Problems can be followed using the Problem-Tracking® feature creating standard SOAP notes.
The E & M Coding Calculator insures the highest-level billing codes are used for all patient encounters while electronically documenting that Medicare documentation guidelines have been followed.

Complete Physical Exam

Vital signs are databased
Text for physical findings is created using a combination of pre-formatted text and user pre-defined phrases.
E & M coding is automatically tabulated.
ECG Interpretation
A wide range of electrocardiographic variables are databased

Laboratory Testing Results

The most common clinical laboratory values
User defined values can also be databased and included in the report

Stress Testing

Actually 3 separate worksheets (Pre-stress, the stress test table and the post-stress findings). A specialize stress echo worksheet is also available.
Pre-Stress Patient evaluation includes patient history, indications, risk factors, ECG and physical findings. The pre-test probability is also recorded.
A variety of stress test tables are provided for the most common protocols. The user may add additional tables at any time.
Post-stress evaluation includes the clinical, ECG and physical findings as well as a post-test probability. Note: Echo stress testing has its own post-stress worksheet (see Echo Worksheets).

Visit Medication Records

A generic worksheet for recording medications administered during a patient encounter.
Visit medications are also entered on other worksheets in the space provided.

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