Speaker 1: Hi, in this video we'll populate an outpatient electronic health record using Allscripts Professional EHR. In a prior video we already described going through the reason for visit, review of systems, reviewing the history, and also looking at the vitals and adding them. Now we'll click on physical exam. I have a comprehensive physical exam that's already populated, and you can hit apply. Under each one of these areas, for instance, if we decide that this patient has a murmur, all we have to do is go through and click on murmurs. We can go through and describe the location, whether or not it's early diastolic or systolic severity. If we click on the exclamation point, it bolds underneath. To go back to the full physical exam, you can click home. It pulls back everything. You can say whether or not the patient is cachectic or thin. And now we've populated the changes to our physical exam. Under assessment and plan, this is obviously where most of our thought process and decision making needs to take place, especially need to justify our decision making for our medical billing. We can search by problem list under the patient's problems. For example, we'll use coronary artery disease. We went to search. We can search under diagnosis, click coronary artery disease, and then we can double click on coronary artery disease. We can say, and then under today's impression, so usually I put everything in this section here that I want to follow the patient with over time. So this will never change, the fact that he had a prior heart cath and the type of stent that he had placed. But what happens on a daily basis does change, and so that's something that I usually reserve for today's impression. There are certain things that I discuss with every patient, and because of that, I have them in a short drop down area. So this customization area here often is the best way to utilize the electronic health record. So I made a lot of shortcuts concerning smoking, follow up concerning echoes and carotid studies, and whether or not the patient should exercise. So for instance, for this patient, we're going to put review of systems. So this is my shortcut for cardiac review of systems and it's populated. In order to create this, we would click on the auto replace options. We would click the plus button. We could say review of, oh, I'm running out of space here, so maybe just hit dot review. And then under here, we can add no chest pain, pressure, shortness of breath, syncope, palpitations. And then we click okay. Now it's populated under here. So we can access it one or two ways. We can click on this down arrow and click on review. Or we can actually type in dot review and it will populate both ways. So for this patient, we talked about, for instance, many things. We talked about the fact that we wanted them to follow a Mediterranean diet. I have some review of the Leon Heart Study. We talked about exercise and the importance of daily aerobic activity. We talked about a journal article from Lancet concerning jogging. And then we can follow up, put something concerning contact or follow up to talk about whether or not they should get back with us if anything changes. So instead of adding just clicks, this creates a more professional looking note. And hit okay. And now when we double click on this, we can see that everything that we clicked on before is populated within the note. So again, to add those shortcuts, you click here and then plus. So some of these studies that I refer to such as the CASL-HF trial, the CLARIFY trial, we talked about the SPRINT trial. These are all included under this area, which is often pretty useful. So speaking of hypertension, let's do hypertension. So we can add hypertension here. We add it as a diagnosis. Say we want to add a medication, so we can call under medications. We can click on the Sartan, double click on it, daily quantity. We can send it to the pharmacy using output, or we can just click okay and make a recommendation. Say we want to do an echo, we can go under procedures. We can do transthoracic echocardiogram, and it populates under here as well. So because we order certain things often, when we created our shortlist for our practice, we included access to smoking cessation and different types of cardiac procedures. So if I wanted to order a transesophageal echocardiogram, or I wanted to order a right and left heart catheterization on a patient, it creates these quick shortcuts instead of having to search under procedures for left heart cath every time I wanted to order one of these other tests. So it makes it a little bit faster to go through and access procedures that are often used for the patient. So finally, if we go under, you can add follow-up to the patient concerning whether or not you want to see them in six months. And this is a basic note in terms of, you know, we talked about the patient's coronary artery disease, the importance of diet and exercise. We talked about the patient's hypertension, maybe we want to add that we talked actually about the sprint trial during the visit. We're going to get an echo, add Losartan, get a left and right heart cath, and now we go to history and physical. And this is a review of the note that we've created for the patient. So it has the basic outline of how we populated our outpatient note. Instead of just clicking on random procedures, such as heart catheterization, it actually has some thought process in terms of why we're doing things. You know, under here, we could say, you know, risk benefits of left heart cath discussed with the patient and she wishes to proceed. So this is a basic overview of how to update the physical exam and populate the assessment and plan for an outpatient note using Allscripts Professional EHR.