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All EMR Charts Are Not The Same
In an age of regulations, you have to maintain complete, accurate, accessible records or you can get into trouble with lawyers, insurance companies, and HIPAA.

Using a paper chart has the dubious benefit of being traditional—if you don’t mind gambling on having lawyers interpret your personal shorthand. Also understand that in this age of technology patients might feel a little restless at the sight of their physician recording his or her observations and assessments in an illegible scrawl. On the other hand, patients are often impressed with offices that have implemented the technology of EMR.

Malpractice lawyers love ambiguity in hand written charts. “Can you tell me again doctor what this sentence means?” Some of the hungrier lawyers cultivate an ability to raise one eyebrow when they ask that question. A slight mocking tone also impresses juries.
Is maintaining records on paper cheaper than using computers? As we have seen, EMR will make you more money in the long run. Since you have to buy hardware and software, yes, they are more expensive in the short term. Can’t dodge that. You’re buying two things here: the freedom to have a life like regular people and increased profit for your practice. That’s a baseball game with your sons now and then and the money for better seats.

So what makes for a good EMR? The best systems will offer charts that you tailor to fit your medical specialty and personal practice. Making custom charts to fit your specialty shouldn’t require hiring a geek with thick glasses or anything like that. It should be something that you and your staff can do quickly and easily.

A good EMR vendor should come up with a chart that will be clear and complete to you and to other physicians who might be working sharing care in a patient.

Among other things, the assessment section will include a review of tests and records and your diagnoses. One of the strengths of a properly structured EMR chart is that it should use specific, straightforward language. It should eliminate inadvertent ambiguities of a physician who might be brilliant at assessing and diagnosing, but may not be that great of a writer. A good EMR chart is clear and direct. Your colleagues and nurses will love it. (So would your patients if they saw one printed out.)

The plan for treatment should be clear and logical, from medications and lab orders to immunizations, instructions to the patient, follow-ups, appointments, recalls, and referrals. It should be easy to understand.

You should be able to beam and print the results electronically to everybody who needs them.
A Good EMR System Should Offer Options In Documenting Encounters
Most vendors offer a consistent, standard layout for all charts. You check boxes and enter typed notes for an up-to-date chart that meets all professional guidelines for quality care. Using these charts, you can document encounters more quickly than writing them by hand or dictating them. Your chart notes will also tend to be much more complete.

But you know what you like. Look for EMR with charts that you can adapt to meet your needs and those of patients. You should be able to quickly design disease-specific charts for conditions that you treat most often. You should be able to designate forms as questionnaires or free-form fields into which you can write or dictate. If you have installed voice recognition software in your office computer, you can dictate notes directly onto the form.
The Advantages Of Structured EMR Notes
You’ll increase your reimbursements.
Getting the right code for every patient is the most profitable step you can take. You make more money by not having to accept less profitable codes because you lack documentation. Good EMR software can help you choose the correct level of service to bill.
You’ll document more thoroughly
“Prompts” on good chart forms help you get all the required data in a physical examination or in a patient’s history.
You’ll document more thoroughly
“Prompts” on good chart forms help you get all the required data in a physical examination or in a patient’s history.

You’ll be assured that you’re complying with HCFA
By proper documentation will ease coding and ensure proper reimbursement.
You’ll save time.
You can complete most of your documentation before you leave the exam room, giving you and your patient more “face” time. And there’ll be no more piles of uncompleted charts at the end of the day.
You’ll improve the quality of your care.
Complete, organized, accurate and readable chart forms—including disease specific checklists and prompts—help you make accurate diagnoses.
You’ll reduce legal risk
If you didn’t document it, legally it didn’t happen. Chart forms give you complete, accurate documentation. Checklists and prompts also help ensure that your history and physical examinations are complete and appropriate.
You’ll improve your professional image
Once a patient encounter is over, your chart is the best evidence of the quality of your care and service. Colleagues, referring physicians, medical staff, insurance providers, lawyers and others might review your charts. Quality EMR software will give you complete, accurate charts to make you look your best.
You’ll improve your standards
When they’re stressed or distracted, even the best doctors will sometimes forget to ask vital questions and fail to document vital information. The best chart forms will help you document a complete and accurate history and physical exam for every patient encounter, no matter how trying the circumstances.
You’ll increase the satisfaction of your patients
Documenting at the point of care reassures patients. Efficient documentation shows them that you’re paying attention to what they’re saying and reduces their waiting times. Make sure your software allows you to document at the point of care.
You’ll make yourself clear
Nobody wants to wade through illegible hand scrawls or long-winded dictations to find out what happened in an encounter. Good forms help other caregivers know immediately what happened—and there’s no delay.
You’ll reduce time and cost spent on dictation.
Chart forms can’t replace all dictation; a written narrative is sometimes the best way to communicate what happened in an encounter. Since chart forms are sufficient to documented most uncomplicated encounters, they can drastically reduce your need to dictate. You’ll still want to provide supplemental dictation for some encounters, but these dictated supplements—combined with a chart form for further reference—can be brief and to the point.
You’ll save money.
The average practice spends a great deal of time creating, filing, and pulling charts. Imagine how much money you’ll save by not having to pay employees to do those tasks. Imagine no more overtime spent catching up on backlogged charts! Most practices also spend many thousands of dollars per year on transcription costs. Good EMR software will drastically reduce that.
You’ll save time
Using chart forms for easy, accurate documentation reduces the fatigue of history taking and physical examination process and will help you get home sooner at the end of each day. EMR also helps save staff time. No more running to find a chart when another physician calls to talk to you about a patient. Just pull it up on any computer, even if you’re not in the office!
How Structured Charts Work
A superior EMR chart form guides you through a complete clinical interview. It does this logically and systematically.

A form will usually contain some information you write in advance—the same on all charts—and some data that will be different from chart to chart. If you’re able to make a chart personal and can write values in advance, you will make sure that you ask and get answers to pertinent questions. You will also make sure that you record findings immediately and that the chart is updated and current.
Structured Charts Are Not One Size Fits All
The better charts are usually grouped by medical specialty, specific histories, problems, and diagnoses; the forms provide you with a database that supports the findings of both structured and unstructured encounters.

You should be able create a chart form for a specific complaint or one for the findings you expect to see on a general exam. You should be able create one for an action plan to resolve a certain condition.

You should be able use one chart for a patient or several—one for the chief complaint, one for the general exam, one for the plan of treatment.

Say you have a patient with a headache. You’ve treated thousands of headaches in the past. When you see a patient with a headache, you ask many of the same questions. How painful is it? When did it start? Is it on the front or back of your head? And so on. You can create a special headache chart that prompts you (or your staff) to ask the correct questions.
How Clinical Findings Are Reported
Clinical findings normally begin with a set of main options on a drop down. Tabs are narrow, specific options on each drop down. You tap a drop down, and then select a tab. You have a lot of flexibility in the way you report clinical findings.

If you have quality EMR software, you’re looking at about ten options:
  • You can tailor your database to your medical specialty.
  • You can incorporate patient intake data in your patient charts.
  • You can view current flow charts from any vital sign, laboratory finding, and flagged, overdue health maintenance items.
  • You can group clinical findings however you want for assessments, compliance tracking, and outcomes.
  • You can group similar data with these findings.
  • You give the system keywords to represent clinical findings or the options of a structured care plans.
  • You don’t have to jump through hoops to store a maximum of formatted information in a progress note. Say what you want, short and to the point or long and detailed.
  • By expanding and collapsing user-selected sections, you ali comments and context to a patient’s chart.
  • You detail your medical services in whatever section of a patient’s record that you want.
  • You can create your own health maintenance program, made individual and specific to the way you practice.
How EMR Helps With Billing
Quality EMR should calculate automatically the responsibilities of both patients and insurance companies. You should know when the claim was created and for how much. The system should detail claims and list responsible insurance companies. It should also flag missing bills or bills that you or your staff entered incorrectly.

You’ll find the details of all claims in the Claim Drawer, although the nomenclature will vary from system to system. These drawers usually have tabs. You key in the name or account number of your patient. In the Claim Services tab enter multiple CPT procedures and charge details—one line for each procedure that you performed.

If you want, you can assign referring physicians, referrals and authorizations to individual claims. Treatment and diagnosis codes and simple validation rules give you lower insurance denials and maximum payments.

If you want to attach notes, comments and reminders for bills and payments, you should be able to do so. Go to the Claims Notes tab or whatever your vendor calls it. Here you should be able to more fully describe and document claims and track and document procedure and diagnoses codes—plus add comments on charges, payments and adjustments.
How To Track A Complete Episode Of Care And Create Insurance Claims
The Claim Case tab should give you everything you need to create insurance claims and track a complete episode of care. This is where you document your care and enter charges for specific ailments and conditions, plus enter case-specific information after you post charges on a patient-per-claim basis.
How To See At A Glance All Billing And Financial Transactions Created For A Claim
Quality EMR software should recalculate patient, insurance, and claim balances as you post charges and payments. The Claim Ledger tab, should give you a detailed audit trail of dates of service, line item payments within claims and patient co-pays.
How EMR software can remind you and your staff of chores related to claims
The Claim Ticklers tab, should give you the status of all tasks related to a claim. It gives you the major billing events for each claim, showing the progress of reimbursements and transfers of responsibility until the claim is paid and written off.

It’s easy to highlight, edit, delete or add additional charges to a claim. Just go to the Claim Drawer, select the right tab, and enter the correct data.
How EMR can help schedule appointments and manage the flow of patients
EMR software can’t solve the problem of late and thoughtless patients, they’re human.

A good EMR system should allow you to make custom calendars so you can schedule patients in a way that works best for your practice. The rules for changing reserved and blocked slots are simple. You know your resources. You know what your patients need. If it will help to keep things moving, you can run individual schedules for doctors, nurses, technicians and staff.

To give you an immediate, visual check of what lies ahead, a good EMR designer should give you visual help, like color coded appointments—different colors for those that are wait-listed, rescheduled or cancelled. Whether you’re a doctor, nurse or technician, you should be able to glance at a color-coded appointments chart and see how things are shaping up.

When you schedule an appointment, a quality EMR system should automatically prepare charts ready for today’s visit. The person making the appointment gives printed instructions to the patient and alerts staff to special issues—history, cancellations, no shows, wheel chair needs, and outstanding account balances.

With a click of the mouse, you should be able to check the status of a single appointment or multiple appointments. You should be able use your appointment book to check the complete clinical and billing records of a scheduled patient. You should be able print encounter and super-bill forms that you designed yourself. Try doing that with paper.
How EMR uses color codes to make a physician’s job easier
Your EMR software should give you the available appointment times for a specific date or a range of dates. Designers often use color codes to show you all appointments, reserved slots and blocked times for a particular day. You point and click to reserve slots for drop-ins, specific procedures or exams.

If a member of your staff has a patient on the phone wanting an appointment, he or she checks the Appointment Finder which gives the user available slots by day, week or month. She should be able to find openings based on availability, range of dates, the time of day or week, the type of appointment, or her preference of physicians. If you have the resources, it should be easy to offer your patient a choice of doctors and facilities.

With a few keystrokes your staff member should be able find and schedule visits in sequence to handle multiple appointments having to do with a single medical issue.
How EMR can help coordinate the use of examination rooms and laboratory facilities
You should be able to tell your EMR system what your doctors will need on a specific date. The software should give you the best available time slots for the combination of resources that you need.

The Daily Encounters tab list all your patients who have scheduled appointments. You should be able include the patient’s photo if you want. Good EMR should track the patients’ progress from their arrival through examination and checkout. You know at a glance where they are, how long they’ve been waiting, and who they’re waiting to see.

The Daily Encounters tab follows no shows and wait-lists. It should verify that your staff has billed every patient and recorded payments, and that encounter forms and route slips have been returned at the end of the day. For a larger view of patient flow you use the Office Flow tab.
Managing the flow of patients through your office or clinic
The Office Flow tab gives you a wider view of which patients have arrived and who is due to arrive. You should know who is waiting in the reception room or an examination room and how long they’ve been waiting. A click of the mouse should tell you what they need.
EMR planning by the week or the month
The Weekly Planner tab should give you the same data as the Daily Planner, only for an entire week. You should be able to click on any day to see reserved and open time. You can match current, waitlisted, and work-in appointments to fit the slots you have available. And you can reserve blocks of time for specific types of service. This helps you make the best use of your resources and plan vacation time for your staff and personal time for yourself.

Your system should give you a Monthly Planner showing a month-long overview of how days are filling up. It should give you morning and afternoon totals. To see the scheduling details of a particular day, just click on it. Color coded icons let you know how full you are.
How an EMR system tracks visits and recall
All systems are different and vary in quality. A good system should track each patient’s last visit and the recall date. When you schedule an appointment, the software should update recalls so no scheduled care falls through the cracks. You should be able to form groups based on recall date, provider, age, gender, insurance company, diagnoses and procedures. And you should be able easily print custom letter and post card mailing labels.
How EMR handles claims
A good EMR gives you all the billing codes at a snap of the finger. You should be able tailor personal codes within the chart to your specialty. The software should generate claims, corrects errors, and submit charges to the patient’s insurance.