Acute Initial Visit clinical charting

Acute Visit is related with an acute or sudden problem or an established

patient with follow-up visit for acute problem or check-up. Acute Visit is
based on usual symptoms or complaints. It can be documented with
specific templates created for chief complaints or generic set of templates
for multiple symptoms or complaints. It is usually managed by Primary
Care, Urgent Care. Example of Chief Complaints: Fever, Cough, Cold,
Abdominal Pain, Chest Pain, Back Pain
During Check-in or Intake process, clinical staff (MA/Nurse/PA) will start
capturing patient details from their dashboard: Past Medical History, Past
Surgical History, Family History, and Social History (detailed Occupational
History, if need be, otherwise basic Occupational History would be covered
in Social History), Current Medications, any lab or radiology report
available and Vitals.
If surgical history captured properly by MA, system will show the same in
graphical manner to provider dashboard. For Provider, he can straightway
capture the same surgical history from body graphics.
If above steps are not performed by clinical staff, then Provider would
capture this information from his dashboard.
Through-out Clinical Charting, user can Save and Go to Next or jump to
another sub-module with one click by using Save & Go to Next or Save &
Go to <select sub-module>
Provider can see whatever the relevant data available and filled by
MA/Nurse, and he can edit the same on the go.
Reference Panel will guide provider for any action. Do not miss item on
top of reference panel used to identify important item make it visible
throughout charting.
Patients demographic information and appointment attributes along with
allergies will be available at top, which is known as Patient Visit Top Option
HPI, ROS, PE and A&P can be captured by various easy data entry
methods plugins- Touch, type, graphic touch, command & speak,
scribble, NLP
In HPI, by default RFV value would set from appointment details, if system
finds it under Chief Complaint list, then it will load elements and values for
the same. Provider can also change it from the favorite list of Chief
Complaints. System will load set elements and values pertaining to Chief
Complaint, not all HPI elements. In case of Chief Complaint not available
then, default HPI template will be loaded.
For graphical view, user can touch on any part and relevant list of HPI,
ROS & PE sub element will be appeared down in horizontal tree
manner.
There will be sync from HPI to ROS, which will be helpful in visit report.
Once Chief Complaints related HPI has been captured and saved, user can
Go to Next sub-module. Here, system will derive Differential Diagnosis
(DD) considering HPI & ROS Data and Patient level data.
ROS template will be system default which can be customized at clinic or
provider level.
After ROS, Physical Exam will be captured by Provider. This template can
load by default based on Provider specialty, which can be again configured

and set as default for Provider or Clinic. Default templates will be available
in system are: General Physical Exam and other Specialties specific
Exams. This step will narrow down Differential Diagnosis and will help
Provider to take next action
Based on findings from the exam, Provider will make a decision to perform
any Lab or Diagnostic Test in-house, if need be. This will filter Differential
Diagnosis further into Possible Probable Diagnosis for the visit.
Under Assessment & Plan, Provider can select Final Diagnosis from:
System suggested Differential Diagnosis (if CDSS is on or
checked) or Most Favorite Diagnosis or Patient Active Problem List or Most
Used Diagnosis.
If CDSS is On and Provider use CDSS derived plan then Plan comprising of
Prescription, lab, radiology, procedure, immunization, patient education
will come from CDSS
Otherwise user can simply create his own plan using Prescription, lab,
radiology, procedure, Immunization, patient education and next
appointment
During charting, left mega menu would help provider for navigate to
any patient level data and/or visit level data, edit the same and return
back, so that no back and forth to different tabs.
Also depend on patient informatics, visit level data and eligibility check,
system can suggest or trigger nearby protocol eligibility.
Also, if procedure is suggested in CDSS, Procedural workflow will be pop
up for charting on procedure date.
Also, Automated E&M code for the work captured.