Documenting a Well-Woman Visit and Colposcopy
See how our adaptive learning technology and touch-based interface helps you document a well-women visit and follow-up with colposcopy. Watch the demo now!
Here is a full transcription of the video:
You can see that ModMed OBGYN was built for OBGYNs by OBGYNs from the moment you enter the system. But not only that, we recognize that not every OBGYN is the same. You’re all unique, and we love that about you.
With an adaptive learning engine that’s layered on top of the hundreds of chief complaints and thousands of diagnoses that our on-staff OBGYNs have built in, ModMed OBGYN will ultimately, feel like it was designed just for you.
So let’s say that we have a patient here for a well-woman exam and she is over 40, sexually active with her husband, not planning on having a baby, no birth control.
We can continue to go through the exam, answering the questionnaire, or we can stop and dictate a quick note:
The patient shared that she and her husband have given up on trying to have a baby, period. They are not using any protection, but don’t believe that they will get pregnant, period.
The system does a great job of picking that up and combining that information with what the medical assistant may have captured in the guided questionnaire.
In the virtual exam room, you will see that again, the system has been tailored to OBGYNs. So we’re going to do a comprehensive exam here. The adaptive learning engine knows what your top 25 impressions are, based on the chief complaint that you selected. So I’m going to go ahead and select the well-woman visit. On the right-hand side, we can do findings. such as an anteverted uterus and bilateral breast implants. This is going to change those areas of the exam that were all marked normal to abnormal, which we’ll see in the note output.
Over on the left-hand side. You can see your most popular plans displayed. This list is based on the preferences of an individual provider – in this case – you.
So if you have a medical assistant logging in to assist you in documenting, and you share that medical assistant with somebody else, this list will be appropriate for whichever provider they’re scribing for. Your most popular plans are listed here.
Let’s say we are going to counsel the patient on breast cancer screening.
That little green circle with the “S” means that if you go in here and you read the counseling that was written by Doctors Hung Ecklund and Nigel Spier, and it doesn’t sound like you, you can make a change, it will stick, and the system will remember for next time.
Let’s say that we want to go ahead and order that mammogram. We’re going to say it’s because she’s over 40. Let’s say that we also want to do a pap smear and HPV test. So, we’ll say “done” there.
Maybe the patient decides to go on birth control, even though they’re not trying to have a baby, but because her periods are getting closer together, and that’s bothering her, we’re going to go ahead and prescribe Loestrin. The adaptive learning engine is going to sort your prescriptions from most commonly to least commonly prescribed, by diagnosis.
From day one, we start you off with the most popular prescriptions for any diagnosis, and that’s work that was done by our OBGYNs on staff. But you can always add your own. You can also see that the system does drug on drug, and drug on allergy checks. You can send the ePrescription right from the screen and see the information on formulary.
So why don’t we go ahead and save the visit note, and let’s see what it has done for us in the background.
So in the background, on the left hand side, you can see our robust medical history. On the right-hand side, we see our chief complaint with the exam. All of the normal findings are in black and then our anteverted uterus is bold and red. We can see that we reviewed these when we ordered and then we have our impression of the well women visit with the counseling, the mammogram we ordered, the pap smear, and HPV co-testing and the prescription. Now we can take a look at RX. The ePrescription has already been sent, but if the patient would prefer to also have a written copy with them, that’s absolutely fine. The order for the mammogram is done, and our patient education handouts are done and these can be sent to the patient portal. You can also print a copy out for the patient.
Now, let’s say that the results come back and the pap smear is abnormal and we need to do a colposcopy.
But this time, instead of starting from scratch with the chief complaint, we can document this visit as a follow-up to the well-woman visit. And this is one way that we are working hard to reduce pre-work that you have to do in other systems because we present everything that you need right from the same screen. So we know exactly why she came here previously.
And now she’s coming in for a colposcopy. So we choose “save” and look how quickly we generated that detailed chief complaint.
Now let’s go in the virtual exam room. We’re going to pull up the impression and say that we are going to do cervical cancer screening. It knew that was going to be at the top of our list, based on the chief complaint. We can go ahead and tap on colposcopy. It’s going to learn what we like to do. Let’s say that we’re going to do colposcopy with cervical biopsy.
The indication is something that we can select and we can note coloscopic sites. We can also document that her last path was on the 15th and it came back positive.
The source of the last pap was in the office and we’ll note that they’ve never had prior treatment.
Then, an image pulls up where we can note where we’re doing the colposcopy. If I hold my finger down, we can make annotations based on the clock formation.
This way you can see exactly where you’re documenting and make sure that it’s done right without any typing. Once we’re finished, we can save that note as well.
And let’s look at our note outputs again. So our note is complete, including the follow-up chief complaint and our procedural note. We have our images showing where the colposcopy was done. Here’s you’ll find suggested coding for the visit with the biopsy and the number of units. Our path requisition is filled out and the patient education handouts have been generated.
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For more information, visit modmed.com/OBGYN or call 561.998.2266