Charting in under 3 minutes with our AI-Powered EHR

Introduction

Charting has never been easier with our Electronic Health Records (EHR) system, designed to provide flexibility that meets your needs. Here’s a quick guide on how to navigate through charting seamlessly.

Step-by-Step Charting Process

Open a Chart: Start by clicking on the chart. From there, select 'Encounter' to initiate a new visit.
Access the Chief Complaint and HPI: Scroll down to the CC (Chief Complaint) and HPI (History of Present Illness) sections, or opt for quick access via the left side dashboard menu.
Choose a Template: For efficiency, select a template such as 'Diabetes DM Type 2.' Our EHR will automatically chart the relevant elements based on the template you choose.
Entering Chief Complaint: If you decide not to use a template, manually type your patient’s chief complaint in the designated field.
Follow the SOAP Note Format: Continue following the traditional SOAP note format. Scroll down to fill out the Review of Systems and Physical Exam sections.
Assessment and ICD section: Next, you will reach the Assessment and ICD section. Our EHR system utilizes AI technology to enhance your efficiency. Click the 'EA Enable Assist' icon for AI-generated insights regarding assessment and plan components.
Lab Orders: Complete laboratory orders by selecting 'Add Order.' Choose your desired orders and click 'Add to List.' Billing codes will be automatically entered under CPT procedures if you have used a template. If not, ensure to enter your billing codes manually.
Prescribing Medications via EHR: Navigate to the E-RX feature to order prescriptions. A window will display all active medications for your patient. To refill an existing medication, just click the appropriate icon. If you require a new prescription, type the drug name into the 'Prescribe RX' field. Thanks to our AI, the EHR automatically suggests the quantity, days’ supply, refill count, and Sig line based on your historical prescribing patterns.
Complete the Encounter: After finalizing your orders and prescriptions, go to the three-lined menu dashboard, select 'Complete,' and then 'Sign' to finish your encounter.
Documenting New Patient Encounters: If you are documenting a new patient encounter, make sure to fill out the patient history fields prior to finalizing the encounter.

With our AI-powered EHR, charting can be accomplished quickly and efficiently, helping you to dedicate more time to patient care instead of paperwork.

Keywords

EHR, charting, AI technology, Chief Complaint, HPI, SOAP note, lab orders, prescription, billing codes, encounter.

FAQ

Q1: How can I start a new patient visit in the EHR?
A: Click on the chart, select 'Encounter,' and fill in the required sections including Chief Complaint and History of Present Illness.

Q2: Does the EHR support templates for documenting encounters?
A: Yes, you can select from various templates which will auto-populate relevant information to save you time.

Q3: What happens if I don’t use a template?
A: If you choose not to use a template, you'll need to manually enter the relevant details, including the chief complaint and billing codes.

Q4: How does AI assist in the assessment and plan components?
A: By clicking the 'EA Enable Assist' icon, the AI will provide personalized insights for your assessment and plan based on the encounter you’ve selected and entered patient data.

Q5: Can I order prescriptions directly through the EHR?
A: Yes, the EHR has an E-RX feature that allows you to manage prescriptions quickly, including refills based on historical data.