EMR Features for Geriatric Patients

The older generation has particular need for psychiatric services. If dementia, Alzheimer’s disorder, anxiety, mental disorders, pain and neurological disorders are left untreated, they lead to increased mortality, further functioning disabilities, worsening symptoms and diminished quality of life. In addition, many mental illnesses can produce physical symptoms, such as pain, headaches, and digestive problems, as well as behavioral problems such as misconduct, interpersonal conflicts, uncooperative attitude, and non-compliance with treatment. The psychiatrist plays a vital role in the medical care of geriatric patients.

Complex diagnostic and documentation tools in PatientTrac EMR make this software a perfect fit for an office-based or hospital-based geriatric psychiatry practice, nursing home, or assisted living facility. PatientTrac EMR helps the physician record clinical information efficiently and document medication orders, including medications’ efficacy, adverse effects and interaction with other medications that the patient is likely to be taking.

PatientTrac EMR can be used on a tablet PC touch screen with Windows 8; documentation may be completed with stylus or finger. This version is excellent for the residential facility psychiatrist; it offers longer battery life and the ability to document on the go in a busy geriatric practice.

PatientTrac’s patient demographic components ensure documentation of the patient’s date of  death and prevents inadvertent medication prescriptions or refills, lab orders or patient visits documented for deceased patients.

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

Geriatric 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). Psychiatric Review of Systems also features a mini mental status examination with cognitive tools, e.g. comprehensive clock test, pentagon drawing and other relevant data elements.

AgitationAnxietyAppetiteCompulsiveBehavior
ConcentrationDelusionsEnergyHallucinationHomicide/Suicide
MemoryMoodObsessive
Behavior
SleepStressors

Each of the specific data elements has logic-based sub-elements to allow documentation on the macro or micro level, depending on the user’s request. For example, in Stressors the clinical elements include sub-elements for symptoms, duration, severity, place and subjective comments. Here the end user can document:

(1) simply normal for stressors
(2) reports stressors, in partial remission or full remission or
(3) a comprehensive level of documentation regarding the stressors review

Example of each are below:

(1) Patient denies increased stressors.
(2) Patient reports increased stressors in daily life.
(3) Alex’s current stressors include social environment and housing. The stress level of these stressors is reported as of severe intensity. He identifies specific issues, which include Alex is experiencing difficulties getting along with 2 residents at Oak Manor. He believes they are “out to get him”. The tension is apparent during meal time. SNF staff had to intervene on 2 previous occasions last month.

Mental Status Examination

During a Mental Status Examination, the provider can document all necessary MSE elements with calculated E/M bullets for determination of visit complexity level. Our MSE is fully customizable; the physician or clinician can set terms for each clinical data element. Users can customize these elements on the fly and begin documenting with the new terms immediately. More about Mental Status Examination.

Physical Examination

In addition to all medical systems, PatientTrac Physical Examination 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.

Geriatric Psychiatry and Behavior Cognition

Specialized Rating Scales are part of our unique combination of clinical tools tailored to the needs of Geriatric Psychiatry practitioners. PatientTrac EMR makes it easier to assess and track complex medical, psychological and social factors affecting the older generation, as well as stressors and living conditions. Geriatric rating scales are built-in in PatientTrac EMR, and available for any physician, RN or PA for completion during the patient visit.

Scales and tests offered by PatientTrac include the AIMS (Abnormal Involuntary Movement), Geriatric Depression, Clinical Dementia rating scale, Geriatric Pain Evaluation, KATZ ADL Scale, and multiple pain evaluations, including the Geriatric Pain evaluation. Using the tablet PCs or slate tablets, a patient can complete the “draw the clock” test, or other testing components, directly on the computer. All images are stored within the patient’s medical chart. PatientTrac presents the rating scale data in a historic report, allowing the clinician to instantly compare previous clock drawing or other scale information in real time.

Customization and Reliability

Our development model allows us to add components, tests or other quantitative data elements within a few days, versus months or years as with most companies. Our clinical database model allows users to perform unlimited scientific queries on clinical and demographic data, which can be used in outcome value measurement as well as clinical trial data.

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 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, the provider can easily print educational handouts for patients and caretakers.

WE ARE DEDICATED TO PROVIDING YOU WITH THE BEST EMR TO HELP YOU TAKE THE BEST CARE OF YOUR PATIENTS!