Documenting With a Smarter Orthopedic EHR
Modernizing Medicine’s orthopedic EHR EMA® is designed to help orthopedic practices deliver their best care faster. Let’s take a look at how easy it is to document a patient visit with EMA.
This patient presents with insidious onset right shoulder pain. The patient has entered their past medical history, allergies and medications in modmed® Kiosk in the waiting room, which helps save time for the office staff and the physician.
The visit overview displays a running note view of the patient’s chief complaint, HPI, review of systems and vital signs. This information can also be viewed in a tile format depending on your clinical workflow.
After an initial exam, the patient has been diagnosed with right shoulder subacromial impingement syndrome. If this is a common diagnosis for your practice, you can build a Protocol on how you prefer to treat these patients, which can really help speed up documentation.
This Protocol includes x-ray interpretation, counseling on shoulder impingement, a subacromial steroid injection and referral for physical therapy. You can easily edit the Protocol as needed for this patient. For example, you can delete the physical therapy referral and instead add physician directed home exercise.
Additionally, you can document any custom findings specific to this patient. The custom findings presented are built into EMA and are relevant to the diagnosis, which helps limit tapping and typing to save you time.
Here, you can easily add an e-prescription for meloxicam. The plan in EMA provides the estimated patient costs to help with patient communication. The patient’s preferred pharmacy automatically populates from the intake kiosk, and this prescription can be sent electronically, which helps save time and paper for your staff and patients.
As you document the exam, EMA collects the required elements to determine the E/M level in the background and suggests what coding might be appropriate based on the services provided. This visit has generated a level 3 new visit.
The visit note output is very easy to read and highlights exam findings specific to this patient in red for easy identification.
The encounter form includes the suggested coding populated as the visit was completed, which is generated based on the documentation and includes CPT codes, HCPCS codes, modifiers and the E/M level. You can then work with your billing office to review these suggested codes and make changes where necessary, which can help to speed up the billing process.
There’s also a patient handout that includes diagnosis information, prescription instructions and post injection instructions. This handout can be printed for the patient and posted to their patient portal.
And just like that you are ready to finalize the visit and move on to the next patient.
If you want to see how EMA can work for you, request a demo today.