Electronic Medical Records
Medical Office Online's Electronic Medical Record is the core feature of the system.
Medical Office Online's Single Source Database (SSDB) design offers the next level in system integration. When a patient is scheduled using the Patient Scheduler, rather than a useless calendar entry being put on the calendar, an actual Electronic Medical Record (EMR) is created, filled out with all of the patient's demographic and insurance data, and given a time and date. It is this document which appears on the calendar. As the provider works through their day, they open up each of the electronic medical records and fill it out from top to bottom.
The Medical Office Online EMR is set up to be extremely user friendly to the Provider. It is set up in a manner that should be familiar to the Provider while offering a myriad of time saving features and devices. The different sections of the Medical Office Online Electronic Medical Record are listed here in the order in which they appear in the system. All of the sections are provided on one page so that the Provider doesn't have to switch tabs.
At the top of the electronic medical record is a large box for the Provider's notes. It is generally recommended that the provider type the note or use customizable "Auto-Fills" to drop in commonly used notes while in the room. If the provider does not type or does not wish to type, then any of the following methods can be used with no degradation to the providers workflow.
- Have a scribe fill out the electronic medical record in the room
- Have a member of staff type your paper notes into the electronic medical record after the visit
- "Copy and Paste" text received in a Word document from a transcription service into the electronic medical record.
The standard set of Chief Complaint and History of Present Illness boxes appear at the top of the electronic medical record. These boxes can be filled out through typing or by using pre-set-up "Auto-Fills" to drop in commonly used CC/HPI remarks.
The standard set of Review of System boxes are given near the top of the electronic medical record. These boxes can be filled out by typing or you can drop in commonly used ROS remarks by using "Auto-Fills" that are set up prior to the visit.
Medical Office Online allows you to create custom Physical Exam Templates that can be added to the individual patient's electronic medical record when needed. Once inserted into the electronic medical record the template can be filled out by typing or by using "Auto-Fills" that are custom created for each template.
Vital signs such as height, weight and blood pressure can be added by the office staff on a separate tab of the electronic medical record and can then be reviewed and/or modified by the provider while visiting with the patient.
Provider Notes / PE Summary
The Provider is given a section to add their own notes as a summary of the Physical Exam they performed. This makes it easier for the provider to assess the outcome/important discoveries of the exam when referring back to the electronic medical record.
The Medications section of the electronic medical record allows the provider to add medications to the patient's current med list, prescribe new medications and refill existing medications. Medications are chosen from a custom medication list that is pre-set by the provider. Prescriptions can be printed or faxed directly from the electronic medical record in as little as three clicks. When the electronic medical record is saved all additions and/or changes are reflected in the patient's current and past med lists.
This section of the electronic medical record allows the provider to refer the patient to another Provider, a specialist, or clinic. The provider chooses the referral destination type and can also choose a specific destination or Provider.
A large box is given on the electronic medical record for the assessment note which can either be typed in or dropped in using a custom"Auto-fill".
Diagnosis / ICD-9 Codes
The Provider is allowed to choose up to four diagnosis codes from a customizable list of ICD-9 codes. This list that appears on the electronic medical record is usually set up by the provider before the visit using our ICD-9 import function.
On the electronic medical record CPT codes are broken up into the following sections:
- Visit codes
- Operation/Procedure codes
- Lab codes
- X-ray codes
- Special Test codes
The provider is allowed to choose a visit code and up to 8 of each of the other code types from customizable select lists. When the electronic medical record is saved, all labs/X-rays/Special Tests ordered show up on the office staff's outgoing stacks.
As the provider fills out the electronic medical record, the E&M counts are quietly being tallied in the background. When the provider reaches the bottom of the electronic medical record they are able to see exactly how many points they have qualified for. The provider is able to put in the required counts in the system configuration and compare the counts that they have amassed while filling out the electronic medical record to the required amount. This system of E&M tracking can result in a substantial increases in the revenue earned by the practice.
The administrative functions section of the electronic medical record allows the provider to do a number of different tasks.
Create Custom form letters
At the conclusion of the visit, with a click of a button the Provider can drop information from the electronic medical record into a form letter in Microsoft® Word. An Envelope can also be printed allowing you to finish your letters in the examining room with little to no typing! If you want to do the letter later you can mark that the visit needs a letter and it will show up on your stack of visits that need letters.
Choose the next visit time and reason
The provider can choose that they would like to see the patient in 3 months for a follow up, for example. When the patient is being scheduled on their way out, the front office staff doing the scheduling is notified of the time and reason for the next visit as supplied by the provider.
Medical Office Online is a fusion of Electronic Medical Record and Medical Billing software. The Medical Office Online Visit form serves as both the electronic medical record and the invoice. After the provider enters the CPT and ICD9 codes and saves the visit, the visit is assigned a Billing Number and shows up in the accounts receivable. Take note that this is not two systems that have been integrated. This system greatly simplifies the patient care/billing process and streamlines workflow. It also allows you to print a HCFA 1500 form or file to an EDI right from the electronic medical record immediately after seeing the patient.
The electronic medical record allows you to attach any type of document that you like to it. This gives you complete flexibility for using other systems with varying types of files. Below are some examples of the types of files that may be useful to attach.
- Letters - external or created from Medical Office Online letter generation (doc, wpd, etc)
- Images - take digital photos in the examining room (gif, jpg, etc)
- Scanned documents (jpg, pdf, etc)
- Files from other/legacy systems (anything; Note: these files may not be viewable from within the MOO system)
Medical Office Online allows you to store handouts or articles that you commonly give to patients. You can then either print them out as needed or hand a pre-printed copy to the patient and mark on the electronic medical record that the handout was given to the patient.
Now that you know what the Medical Office Online electronic medical record can do, why not take a Test Drive and try it out.