We designed our chart forms to be very simple to implement and use. Because of this philosophy you'll find that we have created the proper balance between your own structured "check-box" documentation and traditional hand-writing. MDoffice chart forms include plenty of open space to allow you the flexibility for critical notes to be written in your own handwriting. The end result is a thoroughly documented, completely up-to-date patient chart following practice designed quality-of-care guidelines.

Chart forms can be fully adapted to the needs of each individual clinic and physician. They provide a structured guide for the clinician, which can lead to improvements in documentation quality over handwritten or dictated notes and speed encounter entry. Chart forms can be designed as questionnaires, free-form fields, checkboxes and drawings and findings can be entered using handwriting, dictation and voice recognition.

Equally important, you can quickly design customized disease-specific chart forms to describe the medical conditions that a doctor performs most often. These include new problems as well as follow-up on established problems. In addition, MDoffice has a standard layout through all chart forms. This facilitates consistency, implementation and physician usage.

Why use structured charts.

Increase reimbursement.
Documentation drives reimbursement. Getting the right code on every patient is the most profitable step a medical practice can take. Chart forms help you avoid down-coding because you didn't document enough. They're the best weapon in the war against lower reimbursement.

Document more thoroughly.
With chart forms, you can have the best of both worlds: you can document faster and, at the same time, document more thoroughly. How can this be? Chart form "prompts" help you avoid missing key factors in the history and physical examination. The history and physical exam are more directed and organized. Information entry is better organized. Electronic notation facilitate quick and efficient information entry.

Assure HCFA compliance.
Don't risk it. You need to assure that you are in compliance with HCFA guidelines. By enhancing the documentation necessary to support appropriate billing, chart forms can satisfy HCFA auditors to support your reimbursement process and keep you out of trouble.

Gain valuable time.
Using chart forms will improve your efficiency of documentation. You can document faster, and at the point of care. Most of your documentation can be finished before you leave the exam room. No more piles of uncompleted charts stacked up at the end of your day. Moreover, this results in greater patient-doctor "face" time, leading to greater patient satisfaction.

Improve quality of care.
Documentation is more complete, organized, accurate and legible with chart forms. Disease-specific checklists and prompts help assure appropriate evaluation of various disease presentations.

Reduce risk.
The best defense is a good offense. Chart forms can be your most effective weapon in reducing risk. In the legal world, if it wasn't documented, it didn't happen. Chart forms reduce risk by ensuring accurate and complete documentation. Moreover, checklists and prompts help ensure that your history and physical examination are complete and appropriate.

Improve professionalism.
How do others judge your care? Well, once the patient encounter is over, your chart is the primary representation of the care and service provided. Colleagues, referring physicians, medical staff, payors, lawyers and others may review your charts. Using a chart forms will help you look your very best.

Improve standards.
Reaching a consensus on "best practice" standards is a difficult task. Chart forms can facilitate this process through use of a common approach. Even the best doctors will forget to ask vital questions and will fail to document vital information, especially when stressed or distracted. Chart forms will help every physician document a complete and accurate history and physical exam for every patient encounter, no matter how trying the circumstances.

Increase patient satisfaction.
Your patients will appreciate your use of chart forms. It can help assure a more organized and efficient approach in assessing their problems. Documenting at the point of care is also reassuring to patients as it shows them that you're paying attention to what they're saying. And best of all, from the patient's viewpoint, waiting times can be decreased through more efficient documentation.

Improve communication.
No one wants to wade through illegible hand scrawls or long-winded dictations to find out what happened in an encounter. All referring physicians and other caregivers want the same thing: "Be brief, be accurate and tell me just what I need to know." That's where chart forms shine. Chart forms enhance communication with other caregivers through improved legibility and organization of documentation. And unlike transcription, there's no delay.

Reduce dictation.
Save yourself time and reduce transcription costs. Chart forms can't completely replace dictation, because a written narrative is sometimes the best way to communicate what happened in an encounter. But chart forms can drastically reduce your use of dictation since they're sufficient to document most straight-forward encounters. You'll still want to provide supplemental dictation for some encounters, but these dictated supplements can be brief and to the point, as long as you have your chart form available for further reference.

Save money.
Utilizing a template system will help you save money. The overtime hours generated in completing back-logged charts at the end of each day can add up to thousands of dollars each year. Improved documentation efficiency helps save on staffing and overtime costs. Moreover, chant forms can significantly reduce transcription costs.

Less fatigue.
Decrease the wear and tear on your body and psyche from endless handwriting. Timely documentation of the patient encounter through the use of chart forms will also help you get home sooner at the end of each day. Chart forms can also save you from the tedious task of dictation. Finally, chart forms decrease fatigue by making the history-taking and physical examination process easier and more efficient.

How chart forms work.

Chart forms are based on complaint-specific problems and diagnoses and represent possible medical findings. Personalized chart forms logically and systematically guide the doctor thru the complete clinical interview process in an organized flow. A chart form is a set of values or results you "expect to find" when you examine a patient with a diagnosis you see fairly regularly.

Let's say a patient comes in complaining of stomach ache. In general, when you see someone with this complaint, you ask many of the same questions. You probably ask when it started, how severe it is, if it's in the left or right side, etc. And given the type of stomach ache your patient has, you may dictate findings that are very similar from one patient to the next. If this fits for you at all, for any of the conditions you see in your office, chart forms can be created that will save you a huge amount of time and money.

A chart form can be created for anything from a Chief Complaint, to the general exam and general findings you expect to see, to the action plan to resolve the condition. Your chart form can contain all of these aspects in one chart form, or you can use multiple chart forms per patient. In other words, you can use as many chart forms per patient as you want. Frequently as many as 3 different chart forms are applied to each patient, one to record the chief complaint, one to record the general exam and one for their plan.

Chart forms can contain some pre-written information that is the same on all the charts, and some information that changes from chart to chart. Personalized pre-populated chart forms ensure that all pertinent questions are answered and findings immediately recorded and that patient charts are updated and completed in a timely manner.

Chart forms are generally categorized under a specific medical specialty and further organized by the specific histories, problems and diagnoses they address. Chart forms provide the physician with a knowledgebase that supports both structured and unstructured encounter findings.

Clinical findings.

Clinical findings are user-defined data for outcomes, assessments, compliance tracking, etc. It allows grouping of similar types of data with these findings for analysis. And it maximizes the storage of formatted information into the progress note without any special procedures or unusual steps. Selectable choices or keywords represent clinical investigation findings and structured care plan options.

Findings are normally characterized by an expanding set of choices that start out with a small set of main choices which then further branches out to finer and finer choices. Findings guide the decision making flow and then at an appropriate point, some action can occur, or some reminder set. Additional findings can easily be added or the existing findings can be modified to meet your organization's exact requirements.

Chart findings are used by providers to arrange their own discipline-specific database around their individual practice styles. Structured clinical findings can vary the level of detail recorded which would be one of the building blocks for chart forms.

The findings that are documented with patient intake and nursing notes are incorporated into the chart along with any modifications made by the provider. Up-to-date flow charts and graphs of any selected laboratory or vital sign data can be viewed and any overdue health maintenance items are flagged.

Chart forms are made up of user-selected sections which represent the content and functionality of a chart and can be expanded and collapsed to add comments and context.

Finally, the entire activity is chronicled in the patient’s record, exactly in the section you want. By simply practicing medicine, you begin to create your own Health-Maintenance Program -- automatically customized to the way you practice.

Quickly document encounters.