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According to Elisabeth Myers, Policy and Outreach Lead at the CMS, much of the data routinely documented as part of the patient encounter C such as the History of Present Illness, Assessment, and Plan, to name a few key document sections C can be incorporated into the patient record within the EHR as unstructured data without in any way preventing the physician and clinic from meeting Meaningful Use.
They peck away at the keyboard, staring at the computer screen--or, even worse, the keyboard itself--while slowly entering a patient's history However, we have also noticed that some physicians are able to type their history of present illness while maintaining eye contact with their patient, only occasionally looking down at the screen.
Our patient's history of present illness was not suggestive of malignancy.
The main purposes of this set of tools are the creation and maintenance of a History of Present Illness report in which the patient's Chief Complaint could be integrated chronologically with related health topics in the patient's database files.
The ability to gather a complete history of present illness information directly from patients supports the physician-patient relationship, an issue of growing importance to patients and physicians," said Matthew Ferrante, CEO, Primetime Medical Software.
Lab orders and results supporting integration with the nation's largest reference laboratories; * Cross referencing problems/diagnosis with prescriptions and lab results; * Clinical reminders and alerts with disease management capabilities; * SOAP (Subject Objective Assessment and Plan) notes including the collection of current condition, history of present illness, physical examination and care plan data; * Suggesting appropriate Evaluation and Management coding to facilitate charge capture; and * Dictation and voice activation
These medical images are an integrated component of the Physical Exam documentation process, whereas similarly intuitive user interfaces are available for documenting the Symptoms, History of Present Illness, Review of Systems, Patient Orders, and Diagnoses/Assessments portions of the patient encounter.
The medical staff member asks some pertinent questions and then arranges for them to complete one or more of PrimeCare(TM)'s 280 History of Present Illness questionnaires ("HPI").