Enabledoc™ Provider Guide describes how Providers and nurses manage their work, create patient notes, review patient charts, order electronic prescriptions or dispense/administer medications, enter patient medical information. review and update current medications, enter and review allergies, enter vitals, enter immunizations, enter devices, enter review of systems, enter exam findings, enter diagnosis, order inhouse and external lab test/review results, create treatment plans, send referrals, and create CareTasks. Providers have the following capabilities:
Provider Dashboard:
The Provider Dashboard displays tasks assigned to the provider, open and in-progress notes, appointments, refill requests, lab results, and other workflow information. Providers can click on a patient name to open the patient’s encounter or chart directly from the dashboard. The dashboard also allows authorized users to view another provider’s dashboard when coverage or appointment transfer is required.
Find:
A provider can quickly open a patient chart by appointment, encounter (checked in patient), notes, patient list and Intake forms. This information can be filtered and used to open encounters, open notes, book appointments, book multiple repeat appointments, edit appointments, edit patient registration, collect payments, Invite Patient, invite patient for Chat, send to portal and do many other things as well.
EHR Module
The EHR module stores and manages patient medical information organized by patient encounters. It begins with the Patient Dashboard, which provides a summary of the patient’s historical medical information and allows users to filter records by date or encounter. A patient summary report can also be printed from this screen.
Letterhead, Menus, & Templates:
Forms allow workflows and clinical notes to be customized for different physician specialties, providers, facilities, and visit types. Forms can be configured to display custom menus, templates, letterheads, and print settings. Each form may be assigned based on the visit type, facility, or provider.
Multiple forms can also be used within a single patient encounter to create different types of notes or documentation. Templates can be designed to capture various types of information using check boxes, drop-down menus, Boolean fields, date fields, text fields, lines, and word processor sections.
Fields may be organized into sections and nested groups to support structured question-and-answer workflows. Data can also be automatically pulled from previous visits or populated with default values to improve documentation efficiency and consistency.
Patient Dashboard
Once a patient encounter is selected, the patient dashboard displays a summary of the patient’s medical history, encounters, problems, medications, new prescriptions, diagnoses, vitals, Orders & Procedures, and notes.
Forms Selection
Any form can be opened and used by adding a form to the encounter and clicking on the form name. This allows the flexibility to create different types of notes for each encounter.
Word processor
A robust Microsoft Word style word processor is provided in the EHR module that allows text, tables, and graphics to be inserted and edited in a note. Information from the templates automatically populates in the notes and can be edited in the note.
Attachments
Documents and images can be attached into custom folders for each patient. Each document can be opened and tagged as reviewed or not
Chief Complaints Template
This template creates sentences describing the patient’s complaints. A SNOMED codes problems knowledgebase is provided to select patient problems, associated problems and problems denied by a patient. These problems can be typed and edited. The problem location, onset, duration, context, quality, and severity can be associated with each problem. Multiple problems and chronic problems can be added. Providers can select from favorites problems list, past patient problems, and past problems the provider has added. Additional history of present illness details can also be captured for each problem, such as patient denies symptoms, aggravating factors, relieving factors, onset date, number of recurrences, and prior history of present illness.
Vitals
Vitals that are captured for each patient encounter can be customized for each provider. BMI and BSA are automatically calculated.
Medical History
The past patient history is a custom template that can be designed for each provider and visit type. Default patient template is provided and can be pulled from the prior visit and updated in each visit.
Current Medications
Patient medications are displayed from previous encounters. Any medications can be selected from the Lexi Comp knowledge base and added to the current medications list.
Prescription
A prescription knowledge base from Lexi Comp provides monthly prescription updates, drug-to-drug, drug-to-allergy and weight and age range checking. An interface is provided to Surescripts® for electronic prescription ordering. Patient education materials are provided for medications as well.
Orders and Procedures
Labs, radiology exams, and other services can be ordered from this module. CPT coded procedures can also be selected and saved.
ONC Certification
(i) “This Complete EHR is 2011 Edition compliant and has been certified by an ONC–ACB in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services”
(ii) The information an ONC–ACB is required to report to the National Coordinator under paragraph (f) of this section for the specific Complete EHR or EHR Module at issue; and
(iii) Any additional types of costs that an Eligible Provider, Eligible Hospital, or Critical Access Hospital would pay to implement the Complete EHR's or EHR Module's capabilities in order to attempt to meet meaningful use objectives and measures. EHR technology self-developers are excluded from this requirement.