Home Forums Discussions General Discussion Two Questions ??

1. What all to scan from the Paper Chart into Amazing Charts ?? What are other members doing/have done ??

2. It is taking me a good 10 min. or so to dictate a note with Dragon, and write the list of Diagnosis for Billing. My Nurse fills in the Vitals, Medications on, Types in the Labs & a brief history.

How much time do other members take to see a Revisit & complete a note ???

I use the prior note as an overall template. I use many templates for each section, and use Dragon for additions/corrections. My average note takes under 5 minutes, probably closer to 2-3.

1- we use a Fujitsu Scanner - nontwain. Works well and is fast. Used for several years and thousands of scans.

2- my staff brings up chart and adds vitals. I can do a note in the office with pt looking over shoulder and done in about 2 minutes (type fast) - really should use a template and populate from old note - most changes are really fast. Use scrip writer for scrips, this autofills the plan, use order sheet for all orders, this also goes in plan. A quick revisit should take 5 minutes or less with exam.

ryanjo, what do you mean that you use the prior note as overall template?

Here's a guide we are using for our scanning of paper charts:
Sorry for the poor formatting, word docs do not copy and paste well......



OV NOTES- ONE YEAR “OV NOTES 1/1/08 – 9/15/09)
Item type “OFFICE VISIT”

LABS- ONE YEAR “LAB NOTES (1/1/08 – 9/15/09)”
Item type “LABORATORY”
PAPS (in back of LAB) scan separate- ALL PAPS
“PAPS (1/1/05 - 1/1/08)”
Item type “PATHOLOGY”

XRAY/EKG – ALL “IMAGING (1/1/08 – 9/15/09)”
Item type “RADIOLOGY”

CONSULTATIONS- ALL “CONSULTATIONS (1/1/08 -9/15/09)”
Item type- “CONSULT”

HISTORY AND PHYSICAL- ONE YEAR “HISTORY AND PHYSICAL (1/108 - 9/15/09)”
Item type “HISTORY AND PHYSICAL”

APROS and PRESCRIPTIONS “RX”
Item type PRESCRIPTION
INSURANCE- MOST RECENT INSURANCE CARD
“INSURANCE” or “BIA”
Item type PT INFORMATION
REGISTRATION- PT REGISTRATION FROM 2009 ONLY
“REGISTRATION” Item type PT INFORMATION
HIPPA SIGNATURE IN VERY BACK OF CHART, one only
“HIPPA” Item type PT INFORMATION




LOOK AT ALL NAMES AND DATES
MAKE SURE IT’S IN CHRONOLOGICAL ORDER

When you start new visit you should have a note that is complete from the last visit - eg just double click the name in the schedule or on the pt. list and it brings up new note. It should be completely filled out from the last visit and all you have to do is change the new findings and plan.

if you have multiple specialties or are working with a patient who has workmans comp or MVA claims, you can pull up the last encounter that was for that visit (the titles show on the drop down) and that saves a bit of time as well for pulling up slightly different notes than regular health exams.

I agree with Steven's response. When you double click on the patient's name in the appointment list, the default note that opens in the new window is a duplicate of the last saved encounter. Or you can use the drop-down menu in the upper right of the Most Recent Encounter window to choose any prior note as a template for the current note. Since many of my patients have the same chronic conditions (blood pressure, diabetes, etc.) covered at each visit, it is relatively fast to update a prior note with the current info.

1, We scan the entire chart. Similar to Sky, we use Administrative, Notes, Labs, Consultant, Immunizations as separate catagories.
2. See Steven and John above, Templates can save a lot of time. If you have a repetitive text, right click +alt to save it as a template, Then later just R click and select. Sometimes HPI, most of the time ROS and Exam can be this way. Also Assessment and Plan can be canned.
I do notes in the room with patients, Probably takes 3 minutes with multitasking. I tried Dragon and found it was a little slower. I may have gotten better with time, but I can type and found it was easier. I occasionally used it for complex HPI's but I have swapped out the computer it was on and it is no longer in the office.

Thanks to all, for input & insights.

Maybe I need to have the Dragon loaded on to the Desktop in the Exam Rooms. Now I need to come back into my office to dictate, complete the note,& get the patient education materials.Maybe that will save a few minutes. I am horrific(One finger)at typing.

I do use the last note to change info for the day's note, search the Diagnosis & send to the front office for billing.
I still need 10 mins. to complete a note. I will keep learning and making changes.

Thanks.

Raj

I think that the EULA allows you to load Dragon Medical onto up to 5 computers, as long as you only use one at a time.