Documenting an OBGYN Patient Visit - ModMed

See how our adaptive learning technology and touch-based interface makes it easy to document a visit in minutes.

Here is a full transcription of the video:

From the moment you log in to Modmed OBGYN, you'll see that this is a modern solution that was built to be iPad-friendly. In fact, our company began in 2010 when the iPad was released, and we've hired OBGYNs to pour their knowledge into the system.

You can see that we have hundreds of chief complaints built into the system. We've also layered on an adaptive learning engine that knows each individual provider's top 25 complaints. And that feature continues to follow you throughout the system.

So let's say that we have a patient here for postmenopausal bleeding. It happened this week for the very first time and she noticed it when wiping.

Now we can continue to go through the exam, answering the questionnnaire, or we can also just dictate a little something.

The patient was concerned because they have not had a period in 12 years and they know that this can't be normal. Period.

As you can see, the system does a good job picking up voice dictation.

Now, let's go into the virtual exam room and begin our examination. So we're going to do a focused G-Y-N exam and we're going to chart by exception. Based on the chief complaint that was selected, ModMed OBGYN is smart enough to know what your top 25 diagnoses are, based on the chief complaint. And again, the list is based on the individual provider’s preferences.

So I'm going to go ahead and select post-menopausal bleeding. Then I can select my findings on the side. So let's just say that we think we’ve seen a polyp and we are going to counsel the patient.

This green symbol, with the “S” in it — that stands for sticky learning.

Not only the system learn your top 25 chief complaints, it also learns your top 25 diagnoses for each chief complaint. It learns your top prescriptions for each diagnosis and sorts them most commonly, to least commonly prescribed.

The system also learns with sticky learning, when you teach it how you counsel.

And you can see that our doctors Dr. Hung Eklund and Dr. Nigel Spear have put in counseling that makes sense. But if this doesn't sound like you, you can go ahead and counsel in your own way, and it will stick and remember what you like to do.

So not only am I going to counsel, but I’m going to perform an ultrasound. We will also order some blood work here as well. And we are going to save the note here.

When I come to the note outputs, you’ll see that our system has been working in the background. Your medical history is pulled forward onto the left-hand side. You’ll also find the chief complaint with HPI, including the dictation that I added, the focused exam, and the bloodwork order. Our counseling is also denoted below along with the ultrasound.

Next, we have our encounter form. Our advanced coding algorithm has suggested code 99213, as this is an established patient with moderate decision-making. If insurance charges were entered, those would also be displayed here. We always want the providers to be aware of this at the point of care.

We also have our bloodwork order and we have our patient education handouts, which can be sent to the patient portal when you finalize the note, or you can print them out. And all of that's been done in the background.

The thing that you don't see on my iPad is that after your lab orders are sent, they are added to the orders log. The patient’s plan isn’t marked complete until lab results have been received and the patient has been notified.

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For more information, visit modmed.com/OBGYN or call 561.998.2266