Chief Complaint History & Physical
Assessment Rx Treatment
CHART is a computerized
medical records/practice management system designed to serve you from the
moment the patient walks through your doors (or before!) through the resolution
of his/her medical condition and beyond.
HELPING
you to eliminate the need for tedious, expensive transcription costs and
exhaustive paper trails, CHART will allow you to input, organize, retrieve, and
store your medical files by utilizing its complaint driven database and
comprehensive reports management system to put your records at your fingertips,
whether you’re interviewing the patient over the phone, in the exam room, at
your desk, or on holiday in Madrid!
DESIGNED
as a complaint driven system, CHART will help facilitate your examination and
treatment process by guiding you through the series of specialized screens,
reports and histories you have personally designed, based on a single complaint
or a number of co-existing complaints.
REAL-TIME
data input in the exam room can generate a report at the conclusion of the
patient encounter. Generation of
E&M codes is possible with the CHART system recommending the proper coding
to facilitate nursing and billing staff.
In addition to revolutionizing the organization and storage of your daily medical records and third party reports, CHART will enhance your practice skills by custom developing an ever-expanding medical information database of relevant medical terms, diagnoses, and treatment plans for your specialty. Transcription is limited to quality control, editing and limited voice dictation.
The CHART paradigm
developed by Dr. Charles Mann is being demonstrated with a customized
Microsoft Access database application.
The CHART application takes advantage of both the power of the
Microsoft Jet database engine and the familiar look and feel of the
Windows environment. It is this
combination of power and functionality, coupled with a user-friendly
interface that makes CHART such an excellent choice for a medical practice. The application is designed to be
intuitive for a new employee, and yet can be customized to grow as your
practice grows. The CHART application
requires a minimum of a 386 PC computer with 5 Meg of memory in order to
run. However, we strongly
recommend a Pentium III with 96 Meg of memory to use the CHART application
to its full potential. CHART can
be used with either a keyboard or a pointing device, and is designed to
work especially well with a touch-screen monitor. Networked practices will find the added
benefit of having all of the information accessible from any individual
workstation.
The patient information sequence in the CHART system allows you to enter new patients or retrieve existing patient information. If a patient has been seen previously, you will have access to information concerning his/her initial exam through his follow-ups and treatment plan. An additional benefit to the physician is the significance of the patient’s chart number. This individual number can be programmed to correspond to any office encounter.
The Summary Sheet, which is one of the most important documents in a patient’s
chart, contains pertinent information summarizing the patient’s situation. Even though it is generated with the initial
visit, this can be edited as necessary at any time.
Data entry form in the database
Office Visit Report
Patient visit report
MANN ENT CLINIC 601 Keisler Drive, #200 Cary, NC
27511 (919)859-4744
NAME: Abe Lincoln CHART #: 2 CHART REPORT
1/1/99 COMPLAINT:
CARY Nasal congestion x10 years.
IDENTIFYING INFORMATION:
The patient is a 50 year white old
male, America president, referred by Dr. Adam Jones, patient of Dr. Wilbur
Smith.
HPI:
The patient complains of constant
nasal congestion which is severe enough to give him headaches. Season changes has no effect on his
condition. There is a 10 year history of sinus, congestion, postnasal drainage,
headache pain. There is no previous
surgery for this condition and no x-rays.
There are no dental problems. The airway today is congested. There has been no recent infection/antibiotic treatment. There has been no allergy testing performed
on this patient. He has had no x-rays.
MEDICATIONS: Zocor, Lipitor
DRUG ALLERGIES: Penicillin (rash)
PAST
MEDICAL, SOCIAL, FAMILY HISTORY:
Past medical history: hypertension,
hypercholesterolemia. The patient is a nonsmoker with no caffeine intake, no
alcohol intake. He has no pets, lives in a nonsmoking home
and exercises moderately. The family
history is positive
for heart disease and hypertension.
Tonsillectomy was performed as a child.
ROS: Cardio-no chest pain, palp; Resp-
no SOB; GI-no abd pain, N&V; GU-no freq/urg; Skin-no
rash/lesions/itch; Eyes-no visual disturb; Musc/skel-no muscle
pain, stiffness; Psych-no deprssn,
anxiety; Aller-no seasonal; Heme/Lymph-no easy bruis, swlln glnds.
PHYSICAL EXAMINATION:
General - healthy appearing white male
in no apparent distress; no communication deficits or assistive devices, blood
pressure sitting 130/85, height 6',
weight 180 pounds. Head and face -
atraumatic; normocephalic; no significant
scars/lesions/masses; no facial or
sinus tenderness; no TMJ crepitus; no asymmetry/enlargement of salivary gland;
facial strength shows normal motor tone throughout distribution of facial
nerve. Eyes - extraocular motility is
intact with no observed gaze malignment.
Ears - auricles normal in size, shape and consistency with no lesions;
canals open with mild cerumen; tympanic membranes intact and mobile; hearing is
intact to whispered voice and finger rub.
Nose - nasodorsum is straight without deformity, nasal vestibule is
without lesions; SEPTUM DEVIATION RIGHT; TURBINATE HYPERTROPHY 4+,
TRANSILLUMINATION DULL BILATERAL.
Oropharynx - the hard and soft palates are within normal limits; there
are no mass lesions, ulcerations or erythema of tongue, tonsils or posterior
pharynx. Oral cavity - moist, pink
mucus membranes, dentition in adequate repair, no lesions identified. ^^Indirect laryngeal examination: airway is clear, vocal cords symmetric with
normal mobility, membranes good color and texture, crisp epiglottis, no lesions
of the lateral pharyngeal walls, no pooling of saliva, no mass lesions of the
piriform sinuses. ^^Indirect nasopharyngeal exam: airway
is clear, no lesions identified, eustachian tube looks normal, choana is clear,
no adenoid enlargement. Neck - no
palpable adenopathy or other mass lesions, no crepitus. Thyroid - no enlargement on palpation. Neurologic - cranial nerves 2 through 12 grossly intact; oriented
to time, place and person.
DIAGNOSIS:
1.
Chronic sinusitis 473.9 Chronic ethmoid sinusitis 473.2 Chronic maxillary sinusitis 461.0 Deviated septum 470
Turbinate hypertrophy 378.0
C0-MORBIDS AND RELEVANT HEALTH RISK FACTORS:
Nonsmoker, CAD, hypertension
PLAN:
1. Recommend CT sinus.
2. Cytology.
3. Duratuss G
prescription.
4.
Nasacort
AQ prescription.
RETURN TO OFFICE: 1 month for follow-up; endoscopic examination.
COMMENTS and MEDICAL DECISION MAKING : Recommended Code 99243
Chronic sinusitis by history. Needs CT scan while trying above
medication. Obtain CT scan and will
discuss at future visit.
Copy to Dr. Wilbur Smith
Charles H. Mann, M.D./hmr 1-3-99
Complaint guided template
Many of patient encounters are for complaints
that are seen often and routinely. The
information collected follows a template with questions specific to that
particular complaint. Common diagnoses
for that complaint as well as treatment plan options are readily available
allowing for a faster, more accurate patient encounter. Medicine by exception is practiced in that
much of the visit is routine and those findings that are out of the ordinary
are noted. Repeat visits by the same
patient begin with a copy of the previous visit and any changes for the current
visit are made.
Physicians Nurses Records
Office staff
Multiple users can be accessing the database at the same time. Information is immediately available for the creation of surgery packs, transfer of records to other physician offices or to the patient, transfer of photos in and out of the computer.
Security is an important issue. The database is not ‘out there’ on the Web, potentially available for access by just anyone. The program is stored on a server/computer in your office and access to it is by password log-on. While patients can register on forms on the Web, it is submitted to the office via email and input into the database by office personnel.
There
are numerous ways to input data into the CHART system: patient registration via
the web/e-mail, patient handwritten registration in the office, nurse
handwriting on the complaint guided CHART sheet, nurse inputting data directly
into the database in the computer, input into a laptop taken to remote
locations such as satellite offices or mission trips with the data merged later
into the office database, old archived records. No matter how or where the data is input, the ease and flexibility
for the physician and nurse work well.
An
especially convenient feature of the CHART system is the immediate capability
of the physician to preview or print a complete record of the patient’s visit,
even before he has checked out. By selecting the Report button, the physician
can choose to print or preview the results of each patient visit. This form is particularly useful when
sending a follow-up letter to a referring physician or in the event of a
requested release of records.
Additionally,
the contents and design of the report can be customized so that a patient may
request and receive a customized report showing only their diagnoses,
procedures performed, treatment recommendations. Physicians may determine what categories of information will be provided
to the patient.
Tool for assistance in determining
level of office visit encounter code, found at bottom of data input forms.
The
program can determine the code level of office visit to charge to facilitate
the front desk check-out procedure for billing and maintenance of insurance
records by providing the encounter code.
Also,
with the use of a scanner, medical reports, lab reports, x-ray reports, actual
photographs may be directly inserted into the patient’s record, either in text
or photo form, and retrieved in the manner preferred.
C H A R
T
Chief Complaint
History & Physical Assessment Rx Treatment
In summary, the CHART database is designed to provide the physician with a simplified, convenient method of formatting patient records from the initial exam through the resolution of their condition. The driving motivation behind the creation of the CHART system was the primary desire to have the data immediately available and available to multiple users at the same time. The flexibility of the system is a benefit to the physician, the nursing staff, the office staff from before the patient even steps through the door until after the patient leaves the building.
The system can serve as a stand-alone module or be incorporated for use with most available office software programs on the market today. If you are interested in how this system could benefit your practice, please give us a call and we will be happy to elaborate on the specific uses of this program and the many benefits and advantages it will bring to your practice.
Mann Ear, Nose & Throat Clinic 601
Keisler Drive, Suite 200 Cary,
NC 27511 1-800-ENT-MANN