Solutions: Electronic Medical Records - EMR - Key Features

From medical history entry, to check-in, to treatment, to check-out and to billing, digiChart provides all the tools and features you need to deliver outstanding care to your patients and manage your practice. Every feature is built with the goal of improving your clinical workflow and making your practice more efficient and productive. Here are some of the features that our OB-GYN customers use daily in practices across the country.

EMR Features

Electronic Medical Record

ACOG Antepartum Record
digiChart OB-GYN maintains a license with ACOG to distribute an electronic version of the Antepartum Record and Flowsheet. As you enter clinical and patient data such as fetal measurements, cervical examinations, pregnancy problems, medications and lab results , the record is automatically updated. A permanent, organized, consistent and legible record is available from any computer with Internet access. This means no extra templates and no reassembled, hard-to-use forms.

Hospital Access
digiChart OB-GYN provides your hospital Labor and Delivery staff read-only access to the ACOG Antepartum Record. This feature is a tremendous convenience for the hospital, patients and you. No more late night calls asking for the patient's records. Everyone operates from the latest patient information and your practice saves time and money because it no longer has to maintain charts at the hospital.

The Patient Portal
digiChart OB-GYN includes a patient history Web site. This portal enables your patients to communicate their medical history from the comfort of their home prior to their office visit. The content of the history is both general and specific to OB-GYN. For OB patients, this data will electronically create a history narrative and populate the ACOG Antepartum Record. digiChart's Patient Portal dramatically reduces time spent gathering medical history, so you have more time to spend with patients on their exams, treatment plans and counseling.

Phone Management
All phone calls can easily be documented and routed to the appropriate person within the practice for follow-up. The phone management section allows any staff member to view all outstanding calls. No more lost call slips. Phone notes include all current medications and allergies, so you spend less time searching for information. All completed tasks, calls and signed-off encounter notes are saved within each patient record.

Clinical Documentation
Documenting with specific OB-GYN clinical content improves productivity, standardization and thoroughness. All patient data, including vital signs and physical examination findings, labs, medications, allergies, body diagrams, abnormalities and other clinical data, appear in the patient encounter note. An encounter note and patient summary are electronically generated. Key women's health information is highlighted on every page for point-of-care efficiency.

Physical Exam
The physical exam section represents the typical exam documentation for all GYN and OB patients. The Delivery page and PostPartum exam were designed to mirror those typical exams, as well. All exams are documented "by exception," meaning that you can quickly capture typical and atypical findings, with few or no comments required.

Medical Decision Making (MDM)
The MDM section is designed to allow you to quickly select diagnoses, procedures, medications, and education materials for each type of encounter. Practitioners can create their own Treatment Plans to include the most commonly used diagnoses, procedures, medication, education and treatment notes. MDM standardizes and automates the documentation for routine encounters and plans.

Prescribing
Medication ordering, refilling, and administration are a major part of any OB-GYN practice. You can create your own set of frequently used medications including dosage amount, frequency, and number of refills. Medications can easily be ordered or refilled and associated with a diagnosis. During the ordering process, medications are screened against the patient's known allergies, other medications and known problems. For patient safety, prescriptions can be printed or faxed directly to the pharmacy.

Test and Lab Results
digiChart OB-GYN can electronically interface with many national laboratory companies. Test results can be automatically routed and flagged to the ordering practitioner or any staff member. Other test results and documents can be flagged and scanned into the Test Results Management section. The Past Due Labs section lists all patients with outstanding test results. Each practice can designate the length of time required before outstanding lab studies appear in this section.

Billing and Coding
digiChart OB-GYN recommends an E&M code based on 1997 Genitourinary Examination guidelines and the documentation and data elements selected. The code can be released, deferred to billing personnel, recalculated, overwritten, or where appropriate, reported by time. With digiChart, the Billing Review allows billing personnel to immediately review and verify the level of service and other billable services before they are entered into the practice management system. This feature helps your practice recognize billable services that are sometimes left off the typical bill.

PMS Integration:
digiChart offers digiChart Practice, which integrates digiChart OB-GYN with our Practice Management System to give you full control of your practice: clinically, financially, and administratively. Should you choose another vendor's PMS, digiChart can integrate any system that uses the standard HL7 protocol. This integration will bring patient scheduling and demographics into digiChart OB-GYN in real-time as changes are made.