Chart Notes Video





Transcript

In just a moment we’ll show you how to chart a patient visit in iSALUS. But first, a quick introduction. So you’re a busy provider who likes healing patients. It inspires you. But you need a new Electronic Health Record (EHR) and you are concerned. You’ve heard a lot of horror stories that are backed up by data. In fact, as many as 79% of providers surveyed say that their EHR was not worth the effort, resources or costs. And the problem is that EHR vendors are creating products that are inflexible, constraining and complicated. They’re trying to force doctors to modify their practice. But at iSALUS Healthcare we changed all that. We took a different approach. We let doctors be doctors and practice medicine the way they want. Our system is highly customizable and as a result we have a 90% customer satisfaction rating.

Since iSALUS is web-based, you won’t have to buy any expensive equipment. You’ll simply log in through an internet browser. A convenient overview for the current day at the top of the providers schedule displays all patient statuses allowing providers to constantly optimize patient flow keeping patients happy and limiting wait times. Important patient statuses can be color coded. Clicking a patient’s gender sign displays a patient’s room assignment, room status, an overview of their demographics, their insurance company and their balance. To pull a patient’s chart, simply click their appointment. Patients falling outside of Stage 1 or Stage 2 Meaningful Use compliance display convenient red exclamation points and specific steps required for compliance. And the award-winning patient timeline screen shows all the patient’s important clinical markers in a single view allowing clinicians to review items with a single mouse click here when reviewing the patient’s vitals as recorded by the Physician’s Medical Assistant (MA).

The provider can click the nurse’s note to see everything that’s been done with the patient thus far. These notes can be customized with different colored texts to meet the practice’s needs. Chart tabs can be added or removed by provider to create a more customized user experience.

Let’s start with an HPI template. You may build multiple HPI templates and only those you wish to see will show up in your drop down list. The HPI section can be customized to display common medical issues managed by your practice. This can be filled out by a nurse, an MA or a physician. You’ll notice these templates do allow practices to dictate what questions the staff asks patients to uncover critical health information. Little blue check marks let you know which sections have been reviewed. And the summary section can be arranged by bullet points, paragraphs or even a combination therein, depending on your unique needs.

In the Review of Systems Template, clicking the convenient “load default” option will load all normal values to save time allowing providers to manage by exception and only focus on abnormal system values. Comment sections can be added for free text entry. And the Healthcare Maintenance section will allow providers to track items like colonoscopies and bone density. Providers can choose from thousands of gold standard exam templates or iSALUS can create custom templates tailored specifically to your practice’s unique workflows. iSALUS has a full dictionary of anatomical pictures so that providers can quickly and easily document specific problems on specific points of the body. As you see here on the Monofilament Exam, clicking one mouse click represents a positive sensitivity, clicking two mouse clicks represents a negative sensitivity. And since the templates are so user friendly, it takes providers very little time to get up and running. It’s surprising that these can be so customizable, yet so easy to use.

iSALUS Healthcare can serve almost every medical specialty because we’ve been building templates for over 10 years and have thousands of templates to choose from. Let’s take a look at a physical therapy knee exam. Here’s an anatomical picture of a knee. You can get very specific in documenting high risk foot care. You can automatically push CPTs and diagnoses codes to the superbill based upon what boxes were clicked during the exam. Once you finish your superbill it is ready to be billed out as a claim, no additional data entry is required. Once you’re done with your visit you’ll be able to find everything that was done with that patient in a SOAP note that was customized to your liking.

iSALUS will even automatically fax your SOAP notes to the patient’s referring provider. And supervising MDs can sign off on charts by mid-level providers by entering a four-digit code. And iSALUS has an advanced E&M coding tool that ensures you’re always coding accurately for services rendered.

And that is why iSALUS customers are doing a whole lot of dancing and not a lot of crying.