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Practice Fusion · Dec 13, 2013

EHR Update: Improvements to diagnosis search and finalization

Today, we updated your EHR with improvements to diagnosis search and the finalization section of SOAP notes.

Enhanced diagnosis search

Thanks to the feedback of our providers, we’ve made diagnosis search more clinically relevant, so you can quickly find the most accurate diagnoses for a patient.

More than 100,000 new terms are being added to the diagnosis library available from the patient’s chart. We’re powering this search behind the scenes with SNOMED CT—a clinical terminology that supports effective encoding of data to improve patient care.

You’ll still be able to select from your frequently used diagnoses and search for the ICD-9 codes you’re familiar with. Now we’ll be storing diagnoses as SNOMED CT in addition to ICD-9. The expanded vocabulary of SNOMED will provide relevant results for synonyms, acronyms, partial terms, common terminology, and even misspellings.

This update will facilitate data interchange through the HL7 CCDA format and set you up for a successful transition to ICD-10 later in 2014.

Try the new SOAP notes

When you select Finalize on any SOAP note dated on or after January 1, 2014, you’ll be taken to an early version of the new chart note interface, formerly known as finalization.

The finalization section of the SOAP note has historically supported several Meaningful Use and Clinical Quality Measure (CQM) requirements, including medication reconciliation, visit type documentation, and screening documentation.

In the new screen, you’ll see new and existing Meaningful Use and CQM requirements for 2014, in addition to a number of new elements designed to support clinical quality and improved patient care. You’ll also be able to edit each section of the note directly on this screen.

The new screen includes:

  • Areas to document screenings, interventions, and assessments
  • Observations of functional and cognitive status
  • Care team details
  • Quality of care indicators, including transitions of care, patient education materials given during visit, medication reconciliation completed, and clinical summaries status

Clinical decision support is also integrated into the new charting interface, with advisories for medication documentation, hypertension, depression screening, and routine diabetes care. Eventually these advisories and alerts will be integrated throughout the chart, so you can receive notices at the appropriate time in your clinical workflow.

In 2014 we’ll continue adding features to this new charting experience, including templates, additional advisories, enhanced spell check, and more. In early 2014, the new charting interface will also be available on your iPad.

These changes appeared Friday, December 13, 2013, in any SOAP note dated on or after January 1, 2014.

Read more about how to use these new features in our Knowledgebase: