This is the fourth and final installment of a four-part series focused on finding the right EHR. You can view the first installment here, the second here and the third here.
In the previo
us installment, I began discussing the S.O.A.P. chart note format in Practice Fusion. In this, the final installment of my four-part blog series, I would like to discuss how I chart a patient visit.
Within the objective area I can use templated sentences regarding findings such as positive orthopedic testing. “Patient today presents with a positive SLR on the right”. Or “Patient today presents with a positive SLR on the left”. Or “Pain with trunk rotation”. I have 20 or 30 commonly used tests. I type these into the ‘O’ template section. Anything else that does not pre-fit can be easily typed in as needed. As appropriate I simply click on the sentence that applies. Keep in mind that I have previously created those sentences. To assist with their creation you can see a video showing you step by step directions or contact Practice Fusion support.
Spinal areas to be ‘adjusted’( the reader may be more familiar with the term ‘manipulated’, however it is more accurate to describe it as ‘adjusted’ and so it will be used) are also templated with structured sentences in the Assessment segment. As an example: “Adjusted Cervical spine segment ??,” or “Manually adjusted Thoracic spinal segment ??” or “Patient tolerated the adjustment well.” (The double question mark is called Note Assist and places the cursor on the ‘??’ as soon as you enter that template item to the chart. This allows me to enter different values very quickly.) These can all be pre-listed in the template and when I click on the sentence it is placed in the patients’ chart note.
Doing this for each of the spinal areas in this way allows me to avoid typing sentences. It is also a tremendous time saver. I no longer have to dictate my notes and then read over the transcription the next day before signing approval for placement in the patient chart. That was not only time consuming but expensive. Or I could have manually typed the entire note. And before that I had to hand-write the note. But trying to read my handwriting weeks later was a problem.
In the Planning section of the note I may wish to have the patient return the next day or in five days or in two weeks. These sentences are input by me to my templates and are appropriately chosen as needed for the patient encounter. Setting this all up, to achieve something that I could use daily, required very little time. Not only that but it is all free.
Practice Fusion offers several videos that really do explain the procedures. Support is available and I have never had a request that was not responded to. I have used the email method when time wasn’t critical and got my response usually in a matter of hours. The few times I felt I needed to speak with someone never had me on hold for over four minutes. I had once purchased a charting program for over $2000, and spent extra for support and updates and on average spent more time than that on hold.
So you be the judge. The people at Practice Fusion are continually updating the program. They are continually asking for suggestions to incorporate into the program. I could not be more pleased.
— Dr. Kaplan
After attending university and chiropractic college on the Eastern Seaboard, Dr. Kaplan migrated to the Seattle area where he lives with his family. In addition to running his own practice, Dr. Kaplan has a background in computer programming and health IT.
