EMR Features for Adult Patients

Clinical notes in PatientTrac EMR are designed to present the user with a structured and disciplined approach to clinical documentation. After completing the documentation, the provider has relevant clinical data to assist in their professional determination of the diagnosis. Clinical data elements in PatientTrac provide both clinical user and reader of the progress notes with a true picture of “what was done during the patient visit,” as opposed to redundant computerized template language.

PatientTrac offers its own custom report engine, which provides complete narrative sentence reporting. This is achieved with PatientTrac’s unique language engine, which converts computer-entered data into complete and logical paragraph and sentence structure. End users can modify each report to fit their particular desires and needs— in fact, each user in the same practice can design their own report or progress note format. As with all PatientTrac elements, the clinical data is maintained in the PatientTrac Clinical Repository database, and is projected on the progress notes in a narrative manner for ease of comprehension.

All evaluation and progress notes include a number of intake components with specialized elements for each age group.

Adult Psychiatric Review of Systems

Starting with our copyrighted Psychiatric Review of Systems, PatientTrac EMR creates a user-driven review of mental health systems. Each system has its own unique set of symptoms, documentation of duration and current status, and the ability to add subjective text (comments).

AgitationAnxietyAppetiteCompulsiveBehavior
ConcentrationDelusionsEnergyHallucinationHomicide/Suicide
MemoryMoodObsessive
Behavior
SleepStressors

Psychiatric Review of Systems.

Vital Signs for Adults

This component documents an adult patient’s height, weight, BP, and other relevant vital signs. Upon entry of data, PatientTrac calculates BMI, BSA and other desired elements.

Adult Developmental History Evaluation

PatientTrac offers both simple and complete Adult Developmental History Evaluation. Our Developmental History component includes the ability to document a complete social history pre- and post-birth as well as health information for mother and child pre- and post-birth.

Past Medical and Psychiatric History

Either simple or complex documentation of past medical history, past surgical history, past psychiatric history, and family psychiatric history are offered.

Mental Status Examination

This component allows users to document all necessary MSE elements, with calculated E/M bullets for determination of visit complexity level. Our MSE is fully customizable; terms for each clinical data element can be set by the user. More about Mental Status Examination.

Physical Examination

In addition to all medical systems, our Physical Exam component includes complex neurological examination.

E-Prescribe and Medications

The E-Prescribe and Medications component offers customized print prescriptions, history of previous psychotropic medications, and active medications with updates from the FDA database. Our medication component includes inform and consent forms with electronic signature capabilities for patients and providers.More about Medications.

Assessment and Diagnosis

PatientTrac includes the DSM-IV and ICD-9 dictionary, which can be searched by description, code or chapter for AXIS I, AXIS II and AXIS III data entry. PatientTrac tracks the highest 12 month GAF for automatic entry of the highest GAF scale for each subsequent visit.

Laboratory and Orders

Our orders component has capabilities for both printing orders and electronic submission of lab or radiology testing, complete with the appropriate CPT code and diagnosis to support the test.

Therapy

One element of the progress note for Mental Health users is Therapy; this includes both general description of issues, severity and progress in bullet points (visible on the progress note), and text area for confidential intake (not visible on the progress note to other providers or on the printed note).

Social History

Our Social History component includes intuitive review of: Education, Employment History, Children, Hobbies.

Living Arrangements: Other inhabitants, name, age, and potential problems between the inhabitants and the patient.

Alcohol and/Substance Abuse: If the question “Use of Alcohol/Substance?” is answered “Yes,” the clinical user is prompted to complete an alcohol and/or substance abuse screening evaluation. If completed, PatientTrac documents the screening in the progress note, and documents the appropriate CPT code for billing for an alcohol/substance abuse screening evaluation.

Tobacco: Clinical user can document the history and type of tobacco use, as well as smoking cessation. PatientTrac documents the appropriate CPT Code for billing the smoking cessation discussion as an extra procedure; this procedure is reimbursed by many insurance companies including Medicare.

Criminal History: PatientTrac includes the relevant state criminal statutes for documentation of criminal charges. Clinical user can document the results of the arrest or charges (e.g. conviction, Nolle prosequi), place of incarceration, custody status, as well as identities of parole officer, prosecutor and judge. Documentation of criminal history is especially important for forensic psychiatry; from our clients’ experience, it appears that courts are impressed with PatientTrac progress notes.

Abuse History: Document type of abuse (sexual, physical or verbal), by whom and when.

Customization and Reliability

PatientTrac progress notes are completely customizable, with different intake elements assigned to different note types. More about customization of the progress notes here.

As with all PatientTrac elements, clinical data is maintained in the PatientTrac Clinical Repository database and is projected on the progress notes in a narrative manner for ease of comprehension.

PatientTrac provides patient education handouts, inform and consent forms, and patient contracts within the software application. We have excellent user tools to create and manage patient education materials. During the visit, a provider can easily print educational handouts for patients and caretakers.

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