Documenting Physical Exam from History Button
You can import previously documented diagnoses and findings from the Physical Exam History. The Assessment section of the exam corresponds to the Physical Exam and will update automatically when a diagnoses is added.
Note from our chief Medical Officer "Our EHR allows for efficiency by giving users the ability to bring forward selected items from previous visits and most importantly, it gives them the option to edit it for today’s visit. Also note that every time you do bring a historical measure forward, it time stamps it in the background, keeping an audit trail that the user looked at it and reviewed it before bringing it forward. This makes our software audit bullet proof from that regard."
1. Click the History icon from the Physical Exam section
2. Previous findings and diagnoses display
3. Select any historical diagnoses to import using the check box
You can update the status and severity, then select Done
4. The history is imported and an assessment has been added
Check all other remaining ophthalmic conditions reviewed as normal
Remember to select a primary assessment
