Does anyone have recommendations as to the best way to add a piece of clinical information to a patient's chart without adding a new encounter?
For example: I perform an EMG on a patient in my office in the evaluation of neuropathy, it is normal. I would like to add the following entry in the chart: "EMG/NCV performed june 30 2011 is normal"
I would like to add it to a place in the patient's chart where I can easily reference it, so when I see the patient next, I can say, "Oh yes, we perfomred that EMG last month and it was normal."
I can't add the entry to "Intervention field" - as none exists in this program
I can't readily add it to imported items as its not a fax.
I could add it to "past Medical History" (a second choice), but it seems I just can't add it without making a new clinical visit (and I don't want the clinical information recorded as a visit - I simply want the information stored in the chart where I have easly access to the test results when I see the patient.
How are others dealing with such situations?
Thanks,
Bruce Morgenstern (Neurology)
Denver CO
