Medical Record Searching For EHR Hybrid
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1 Dental Information Categories Admin Financial Management 97% Have This Clinical Information Management Only 1% Have This Dental Imaging Management 60 % Have This
2 Dental Information Categories DSN PerioExec Admin Financial Management 6% Have This Dental Imaging Management 6% Have This Clinical Information Management 4% Have This Apteryx Xray Vision
3 Clinical Records Historical Format Chief complaint History of signs and symptoms Physical evaluation and assessment Review of Systems Diagnosis Plan of care
4 The SOAP Format Subjective documentation patients description of signs & symptoms and their history Objective: examination and documentation of objective findings abnormalities, signs of pathology or trauma, lab test findings, radiographic observations Assessment & Actions taken diagnosis followed by treatment or medications Plan: further treatment, tests or observation
5 What do these approaches share? Systematized approach to performance of a procedure and documentation of the procedure. A process or algorithm for a procedure Utilization of standardized nomenclature The use of terms that are readily understood by peers with comparable training and experience
6 Design Formats for an EHR Free text: typing or dictation followed by transcription PROS: allows the writer to describe things with no limitations on how or what to say CONS: who likes to type takes too much time Templates: procedure specific documents for each type of procedure performed in the practice PROS: just copy and paste your documentation its fast CONS: it may not be accurate unless time is taken to edit it, which is time consuming Structured records using standardized nomenclature PROS: the structure can be the same as the algorithm for performing the procedure the structure as a check list CONS: the glossary and structure may limit the user from documenting exceptional observations or events
7 Design Formats for an EHR Hybrid: combines a structured format using a standardized nomenclature with the ability to add free text (typed) documentation for unusual observations or events. PROS: eliminates the confinement of a structured record CONS: the most difficult and expensive to research and program; must be updated periodically to stay current; some users don t like the lack of ability to modify the structure and terminology to suit their desired result. This hybrid design is what DecisionBase uses
8 Clinical Documentation: EHR Deployment Techniques Publ by: California HealthCare Foundation, Figure 1. Structured Vocabularies as Subset of Structured Data The use of structured vocabulary to record diagnoses, symptoms, surgical procedures, treatment and drugs multiplies the benefits of EHRs by capturing clinical data in words or phrases that have standardized definitions. Unlike handwritten or typed free text, structured vocabularies enables the computerized analysis of data for patient care, research and evidence-based medicine.
9 The DecisionBase graphical User Interface offers a rich array of information for instantaneous use while also being a dashboard from which you can access other clinical information applications on your network or sources on the web
10 User Interface Design
11 In the next slide you see the user interface of the most popular medical EHR for small and medium sized practices. Note its similarity to DecisionBase
12 User Interface Design
13 The next slide shows the NON-graphical user interface of another clinical EHR for Periodontics Its UI makes use of hierarchical lists a design method that was popular in the 1990s before Graphical User Interface design became popular It is obviously less intuitive
14
15 DecisionBase s Procedure Specific Check Lists allow you to create notes without using a keyboard such as from an ipad or Tablet
16 Dr. Atul Gawande has documented how simple check lists used during medical care can enhance the quality of care saving lives and millions of dollars. DecisionBase s procedure specific check lists can reduce errors improve diagnostic decisions, care outcomes, the quality of clinical records and communications
17
18 Each of the green groups below is a check list
19 The next slide is a view on another periodontal EHR s periodontal chart 1. It allows for the documentation of Probing depths 2. CAL 3. Recession 4. Gingiva 5. Bleeding points 6. Exudate 7. Mobility
20
21 The next slide is a view of DecisionBase s periodontal chart It allows for the documentation of: 1. Probing depths 2. CAL or attachment loss (computed by the S/W, 3. Recession 4. Hyperplasia 5. Gingival width 6. Bleeding points 7. Exudate 8. Furcation involvement 9. Tooth mobiity 10. Various items of periodontal morphology and tooth related items (diastema, extruded, buccoversion, etc) 11. Tooth by tooth prognosis 12. Plaque scoring and display 13. Calculation and display of Bleeding and Exudate scores 14. Graphical display of probing depths 15. Spreadsheet organization of #1-11 for ease of view & analysis
22
23 Letters: Your best way to market your services to referrers
24 Advantages of Electronic Records Ease of creating quality documentation Ease of communication with staff & ref docs Security of patient records Access from anywhere via Wi-Fi Better risk management higher quality of care Reduced administrative costs Send correspondence electronically Write and send prescriptions to pharmacies electronically Better organize and utilize all clinical information
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