Explanation of Medinotes E EHR Features

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Accessibility

• Accessible and organized patient folder
  • Allergies
  • Past Medical History
  • Treatments/Diagnoses
  • Multimedia links to images, etc.
  • Alerts for the patient
  • Remarks about the patient
  • Patient Overview and Patient Summary
• Common/Topic/All Design makes it easy to add information quickly
  • Common - This tab is user-definable. For Allergies, you are able to show only the allergies that you use frequently to make your list more manageable.
  • Topic - The Topic tab is simply a categorized tree diagram that allows you to pick your specific history items from the category headings.
  • All- Type in the first few letters of the item that you're looking for, and the "All" tab will search the database for the history item that matches your description.
• Patient Monitor Expansion Module
  • See more of your patients information on one screen with custom data panels
  • Add information to the patient's file from the front screen
  • Create custom data collection screens that can be used to pre populate new notes
• Practice Desktop Expansion Module
  • Access information across all of your patients from a separate screen
    • Alerts
    • Incomplete Notes
    • Messages
    • To-do's
    • Preventive Medicine
    • Notes without bills
• Document Management Expansion Module
  • Bring scanned documents or digital pictures into the Charting Plus database
  • Create a truly paperless office
• Drug Interactions Expansion Module*
  • Real-time drug to drug interaction checking
  • Real-time drug to allergy interaction checking

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Ease of Use

• User-friendly design and consistent icons allow users with limited computer knowledge to navigate the software quickly
• Only 3 main screens to learn for general use - Patient Folder, Note Window and Object Explorer
• Option settings allow you to tailor the program to your needs
• Online help file is always available for reference
• Color indicators in the Patient Folder define rows for better at-a-glance viewing
• Common lists in many of the history dialogs allow you to define the choices that you use more often

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Comprehensive Charting

• Single screen "What you see is what you get" template - no need to move to a completely different screen to enter subjective, objective assessment and plan
• Default phrasing makes it possible to chart by exception
• Templates are completely flexible - you can tweak the provided templates for the work in your practice
• Easy to document multiple chief complaints
• Color coding for viewing at a glance
  • Black Text - This is simply text which has been hard-coded into the template.
  • Blue Text - This is a default value for a pop-up window.
  • Red Text - This is an optional pop-up window that can be clicked if needed.
  • Green Text - This signifies that the user has activated the dialog and made a change.
• New Note from an Old Note
• Note on Hold
• Macros pull demographic or other stored information directly into the note
• Prescription objects can be created and embedded in templates for routine encounters, making it even easier to create prescriptions

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Graphic

• Draw on anatomical diagrams or digital pictures and add them to the body of the note
• Graphic objects allow you to quickly document the anatomical location of the condition
• Hot Spot Editor utility allows you to add custom images to the program for use in graphic objects

 

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Coding Features

• ICD-9 and CPT codes licensed from the AMA
• E&M Wizard suggests appropriate codes based on the information documented
• Custom History of Present Illness based on a Chief Complaint with E&M credit

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Efficient Workflow

• Enhanced Data Repopulation for optimal efficiency
  • Pull medical history from the patient's record
  • Pull object data from a previous note
  • Pull object data that has been added to the patient's record without a note
• Daily Patient List - allows the physician to quickly pull up the patient from the daily list without having to search the entire patient list
  • Interfaces with electronic scheduling
• Template Wizard makes it simple to create custom templates for your practice
• Integrated Office Tasks - just a few clicks
  • Physician Referral Letters - In only 4 mouse-clicks you can create a professional letter to refer a patient, or thank another physician for their kind referral. The letter includes either the full patient note, or just the impression and plan sections for their reference.
  • Patient Instructions - Customized Patient Instructions can be printed and sent home with the patient regarding their care.
  • Patient Letters - Similar to a referral letter, the patient letter is simply a letter template that can be printed and sent to your client.
  • Physicians Orders - When an order has been documented in the note, a worksheet can be printed to show what the physician has ordered.
  • Prescriptions - Create a script right from the program using the extensive medical library. The information for the script is also included at the bottom of the patient's note, and in the patient's medications folder for easy and consistent reference.
    • Custom script layouts
    • Multiple scripts per page
    • Drug Interaction Module available*
  • SuperBill Statements - The Billing Wizard pulls the billing codes from the dialogs used in the exam documentation. Simply associate the Diagnoses with the appropriate Treatments, and print the SuperBill Statement. (Some of the billing interfaces allow a direct transfer of this information to their program.)

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Designed to work the way you do

• One of the most flexible systems on the market
• Medical content is infinitely customizable
• Templates promote better, more comprehensive documentation
  • Fields can be set as "required"
  • Can be layout out in a narrative or list format
• Wireless enabled
• Tablet PC enabled
• Speech Recognition enabled
• WAN through Citrix or terminal services
• Full access without a dial-up using the Charting Plus Synchronization module
  • Synchronization allows remote users to access a full database and synch the data to the main server when they return
  • Perfect for on-call rotations, hospital rounds and nursing home visits

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Security

• One keystroke to log out of the program
• One keystroke to remove all patient data from the screen (without logging out)
• Certified for HIPAA
• Reliable SQL database
• Backup and restore functionality
• Access based logins - 3 levels of accessibility based on the user level
• Custom Security Add-on Module
  • Restrict individual users or groups from program features, or patient accessibility

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HIPAA Certified

• Certified for HIPAA regulations by the HIPAA Academy
• Audit trails to denote what changes have been made to patient records, and by whom
• Program access based on user license levels
• Password security
• Automatic program logout after a period of inactivity

 

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Specialty Features

• Preventive Medicine - A rules-based system that allows physicians to set custom reminders for preventive care elements (i.e. set a rule for mammogram reminder every two years for all women over the age of 40)
• Growth Charts - A growth chart can be completed for pediatric patients based on the age, height, weight, and head circumference. This feature creates a dynamic line graph representing the charted values over the lifetime of the patient using either English or metric measurements.
• Body Mass Index - Charting Plus calculates the Body Mass Index based on the height and weight added for the patient.
• Prenatal Explorer - Several dialogs have been bundled together in what is referred to as the Prenatal Explorer. This feature of the program includes:
  • Estimated Due Date Calculator
  • Prenatal Visit Dialog
    • Fetal movement, position, and heart rate
    • Prenatal lab values
    • Mother's weight, blood pressure, and fundal height
• Contraception History - The Contraception History dialog is used to keep a historical description of contraceptive methods used by the patient. Includes detailed lists of barrier types, and oral contraceptives.
• Obstetric History - The Obstetrical History dialog allows a physician to track all of the past pregnancies for a patient. This dialog includes:
  • Birth weight
  • Length of Labor
  • Duration of Pregnancy
  • Complications
  • Delivery Method
  • Gender
• Immunization History - The Immunization History dialog is used in General Medicine to complete a immunization record for the patient. This includes childhood immunizations and travel boosters
• Vision Objects - Specific dialog objects for vision exams, visual acuity, keratometry, etc.

*DIT Drug Risk Navigator™, Copyright by DIT Drug Information Technologies, Potomac Maryland