See how to document patient visits quickly and easily using ModMed®’s urology-specific EHR, EMA®.
Here is a full transcription of the video:
Hi, I’m Dr. Nadeem Dhanani, Medical Director of Urology at Modernizing Medicine and a practicing urologist. I‘d like to show you how quick and easy it is to document a patient visit using EMA, our urology-specific EHR. Our patient, John Doe, is coming in today for gross hematuria, so Iet’s add that as his new chief complaint.
Notice that gross hematuria comes up as one of the top choices. That’s because it’s something that I commonly see in my practice, so the system has moved that complaint to the top of the list through adaptive learning.
Next, I will go through and answer as many or as few of these questions as I’d like. I want to note that the patient has painless, gross hematuria for two weeks. It’s been getting worse and now he’s coming in. Just like that, I’m done with my history.
Let’s move on to the exam. Since gross hematuria is something that I see often in my practice, I will use a protocol that I customized. It will set up my physical exam for me and it will order my tests.
I will also note on the exam that this patient was found to have a prostate nodule. I want to be able to document that and I’ll use the body diagram for that in order to help illustrate what it is that I found. I’ll also order a PSA since this patient did have a prostate nodule. And with that, I’m done with my documentation.
Let’s now review our outputs. First of all, in terms of my note, my chief complaint is easily found here. You’ll see that I have a paragraph of history which was obtained simply by tapping the screen without any typing or dictation. My physical exam is documented, also highlighting the area of abnormality that I palpated on the patient’s prostate.
Here you’ll see the impressions and plans for the gross hematuria, and you’ll also see where I counseled the patient. The details of that counseling are attached. Next, you’ll see where I ordered some tests and labs. I ordered a CT program and a urine cytology. I also scheduled the patient for follow-up for cystoscopy. Because I found a prostate nodule, I also ordered a PSA.
My orders were generated alongside my documentation, so you’ll notice here the orders for the images and the labs. It also generated a path requisition label. I can easily review the documentation and orders the system suggested to make sure they’re correct, and if I want to make any changes before finalizing, I can do so. Once I’m happy with the documentation and next steps, I can finalize the note.
And with that, the visit and documentation is complete, and I can move on to seeing my next patient. This is just a sampling of EMA’s many tools and features that can help modernize your urology practice and make your practice more efficient.