Patient Info
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The Patient Information screen provides a quick and clear
display of all basic patient data, including:
  Patient ID, Name, Birthdate, Gender, and New or Established patient status
Basic visit data including Visit Date, Doctor Examined By, and Service Category, Type and Modifier
Also allows tracking of Resident Doctor and Teaching Physician activities
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History
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The History screen allows documentation of each of the history elements for a patient at the time of the encounter:
History of Present Illness
Review of Systems
Past, Family, & Social History
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Physical Exam
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The Physical Exam screen allows the selection of all specific examination elements performed based on the selected Exam Type:
Easy drop down for selecting appropriate Exam
Convenient on-screen counter for Elements Selected
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Medical Decision
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The Medical Decision screen is based on the physician’s evaluation of the patient’s Presenting Problem(s). Specific data displayed depends on the selected Calculation scheme as follows:
94/97 Calculations: Enter all Diagnoses or Management Options, and Data to be Reviewed.
99 Calculations: Enter all Presenting Problems, Diagnostic Procedures, and Management Options.
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Risk Decision
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The Risk Decision screen allows the data entry of all Presenting Problems and the selection of Diagnostic Procedures and/or Management Options
Color-coded levels displayed as each Risk Decision element is selected
Notes field available at all times for adding details and clarification
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QAudit
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The QAudit screen provides the ability to track quality control data.
In general, there are (3) categories of QAudit Information:
Track the presence or absence of charting elements such as "Is legible", or "ABN completed".
Track completeness of CPT and ICD-9 coding.
Quickly select and present your Recommendations based on your QAudit Quality review.
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