Documenting With a Smarter Otolaryngology EHR

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Here is a full transcription of the video:

Hi! I’m Dave Lehman, senior medical director of otolaryngology. I’m going to show you how I use EMA in my practice to quickly and efficiently document a visit. I’m going to start by entering my history, and go by taking a history. You can see under historical summary this is a past narrative the follows the patient, avoiding the need to look at old notes or cut and paste. I’m going to take my chief complaint. So today this patient is complaining of hoarseness. He has hoarseness that is described as raspy, occurs all the time, has been going on for about six months, moderate severity, and he has associated dysphagia to solids, heartburn and some mild pain with swallowing. A history is now complete. 

I’ll move on to my review of systems. The patient has also filled out on modmed kiosk in the waiting room, so I’ll review that and save it. Moving on to my exam. So I put down my iPad before my exam, and when I’ve completed that will document the remainder of my note by using a Protocol. So a Protocol is a user-defined combination of diagnoses and plans; something that is commonly used and user defined. Now that that’s complete, my note is complete as well. And I’ll show you the output.

So we have our HPI written in prose format, my exam with the abnormals bolded in red and then summaries of my impressions and my plans. You’ll see here we have an automated separate note for my flexible laryngoscopy, a patient hand out has automatically been rendered as well including everything that I’ve counseled the patient on. An order form for a swallow study has been filled out for my MA as well. And this is again all automated to save them time, and my coding has been done for me. So as you can see EMA is an incredibly efficient tool to allow me to document as accurately as thoroughly as possible. There are many other features and tools to better document and save time that I’d love to demonstrate if you’d like to request the demo. Thank you.

 

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