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Patient Evaluation Worksheets

Patient visit notes are generally created by assembling one or more diagnostic or therapeutic worksheets. A listing of the currently available diagnostic and therapeutic worksheets include:

Clinical Worksheets

Clinical Note (complete)

  • Includes sections for HPI, PMHx, Intervention Hx, Device List, Medication List, Allergy List, Family Hx, Social Hx, Physical Ex, Systems Review, Cardiac Risk Factors, ECG, Other testing results and Assessment & Plan. In each section the user has the option of using a specialized worksheet, pasting in preformed text, using text and data from previous encounters or entering the data manually.
  • The management plan of Medical/Surgical Problems can be followed using the Problem-Tracking® feature.
  • The E & M Coding Calculator® insures the highest-level billing codes are used for all patient encounters while electronically documenting that Medicare documentation guidelines have been followed.

Clinical Note (follow-up)

  • The management plan of Medical/Surgical Problems can be followed using the Problem-Tracking® feature creating standard SOAP notes.
  • The E & M Coding Calculator insures the highest-level billing codes are used for all patient encounters while electronically documenting that Medicare documentation guidelines have been followed.

Complete Physical Exam

  • Vital signs are databased
  • Text for physical findings is created using a combination of pre-formatted text and user pre-defined phrases.
  • E & M coding is automatically tabulated.
  • ECG Interpretation
  • A wide range of electrocardiographic variables are databased

Laboratory Testing Results

  • The most common clinical laboratory values
  • User defined values can also be databased and included in the report

Stress Testing

  • Actually 3 separate worksheets (Pre-stress, the stress test table and the post-stress findings). A specialize stress echo worksheet is also available.
  • Pre-Stress Patient evaluation includes patient history, indications, risk factors, ECG and physical findings. The pre-test probability is also recorded.
  • A variety of stress test tables are provided for the most common protocols. The user may add additional tables at any time.
  • Post-stress evaluation includes the clinical, ECG and physical findings as well as a post-test probability. Note: Echo stress testing has its own post-stress worksheet (see Echo Worksheets).

Visit Medication Records

  • A generic worksheet for recording medications administered during a patient encounter.
  • Visit medications are also entered on other worksheets in the space provided.
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