iPatientCare Blog - Top 10 Internal Medicine EHR Features to help you solve your Documentation Problems

Top 10 Internal Medicine EHR Features to help you solve your Documentation Problems

Internal Medicine has grown increasingly complex and specialized and no longer can a doctor do it all single-handedly. General internists need to be well-equipped to deal with whatever problem a patient brings—no matter how common or rare, or how simple or complex. It becomes really difficult for them to provide timely, reliable, precise, consistent, clear, and complete documentation in patients’ charts.

As a result, they are always looking for solutions that work according to their routine, gives them more time, and leads to the efficiency of work. In this article, we shall discuss some electronic health record features that can help them solve their documentation problems.

1. Integrated Electronic Prescribing Functionality

Problems related to illegible physician handwriting, sound-alike medications, orders taken on phone, wrong diagnoses being embedded in the chart, coding errors can be diminished using electronic prescribing within the specialty-specific EHR.

iPatientCare’s advanced electronic prescriptions speed up the workflow for each physician using it while ensuring patient safety. The intuitive touch screen-based interface makes it easy for internists to prescribe right from the point-of-care.

2. Intuitive Visualizations with easy-to-consume Format

Medical data that comes within the EMRs are often voluminous, complex, unstructured and difficult to integrate. The rate at which the volume of medical records is growing is alarming, making it difficult to obtain important information. This also hampers a physician’s diagnostic reasoning and the efficiency with which he/she works.

An ideal electronic health record should present medical data in intuitive, understandable, recognizable, navigable, and manageable formats, enabling the users to rapidly extract useful information from medical records.

iPatientCare Internal Medicine EHR is designed to provide an interactive display for doctors with simplified navigation to extract patient’s medical information easily, and for patients to record and track their personal medical conditions and history.

3. Quick and Real-time Note Entry

Standardized responses to the clinical queries listed in drop-down menus or in tabular displays requiring single or multiple tick-box responses ensure quick note entry. Accurate data entry is facilitated by applying conditional logic in the system to guide data entry only into those fields that are relevant for a particular patient.

Top 10 Internal Medicine EHR Features to help you solve your Documentation Problems

Data captured within iPatientCare specialty EHR automatically populates a template to generate a visual report that can immediately be made available for the patient and for electronic transmission to the referring general practitioners.

4. Flexible Charting Styles

Electronic health record for internal medicine with an intuitive interface with least time-consuming means of data entry provides internists with an expressive power to describe the patient’s condition and other health-related events.

iPatientCare specialty EHR for Internal medicine allows internists to easily document patient data using multiple data entry methods such as point & click, voice recognition and handwriting recognition with flexible charting options that can be beneficial to their patients.

5. Enriching Digital Data Repository with Structured Vocabulary

The use of structured vocabulary to record diagnoses, symptoms, surgical procedures, treatments, and drugs multiplies the benefits of specialty EHR by capturing clinical data in words or phrases that have standardized definitions. The structured vocabulary allows users to measure the effectiveness of specific treatments.

iPatientCare Internal Medicine EHR provides internists with forms and terminology that can easily adapt to any clinic’s workflow and unique needs.

6. Comprehensive Linear View of the Patient’s Care

EHR generated ready review of prior relevant information, such as longitudinal history and prior physical examination findings, serves valuable in improving the completeness and quality of documentation as well as establishing context.

iPatientCare’s easy-to-use EHR enables ‘review/edit, attest, and copy/forward’ of specific prior history or findings, improving the accuracy, completeness, and efficiency of clinical documentation.

7. History-rich Notes

Information gathered during past visits is widely used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up. iPatientCare specialty focused solution facilitates attainment of these goals in the most efficient manner possible without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians.

8. Specialty Specific Customization

The ability to customize enables doctors to create templates based on their practice and speed up the patient encounter process. It provides them the freedom to create an assessment that contains their way of thinking, the questions they would like to ask, and the things they like to check for. Advanced customization can further enable the physician to create a checklist for patient that comes in later with any previously treated medical condition.

iPatientCare provides its specialty doctors the flexibility to choose what features and templates to keep. It also allows them to design their own template, which gives them ease while working and more time is allocated for the patient care.

Related Article: How Internal Medicine EHR makes the provider’s life easy?

9. Clinical Documentation Improvement (CDI)

Ideal clinical documentation gives a vivid picture of a patient’s situation. The patient chart should uncover full patient information through unstructured data such as procedure notes, observations and discharge summaries.

Technology tools such as natural language processing and computer-assisted coding integrated with the electronic medical record software offers an electronic physician query platform and help provide suggestions for missing diagnoses. It also can help weed out irrelevant abbreviations doctors might use in their notes, preventing medication errors.

10. Image and Document Management

Having Imaging and document management right in the system is a great benefit to physicians. Such features enable physicians to streamline their workflows in a hassle-free manner.

In addition to streamlining workflows, this feature enables doctors and their staff to quickly sort, search and summarise documents, radiology images and videos from anywhere into the integrated database.

The integrated module of Document and Image management within the iPatientCare Internal Medicine EHR enables uploading large images, scanned documents, x-rays demonstrating endoscopic diagnosis with multi-scan facility and integrated fax management module for maintaining a hybrid database.

What’s special about iPatientCare Internal Medicine EHR?

iPatientCare Internal Medicine EHR not only provides the latest clinical data, charts and patient information but also ensures that the data is HIPAA compliant, provides customizable standards and provides internists with a real-time clinical information and intuitive dashboard to assist in care decisions. Inclusive of all above-mentioned features, iPatientCare offers an easy to use, all-in-one solution for internal medicine practices that integrates medical visits, procedures, and billing in a single system.


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