Guide to Updating Visit Reasons, Systems Review, and Physical Exam in Allscripts EHR (Full Transcript)

Speaker 1: In this video, I'd like to show, using Allscripts Professional EHR, how to update the reason for visit, review systems, and physical exam. So we have a test patient loaded up now, and we can go under here, under reason for visit. We can click on previous complaints. If you've seen the patient before, these would be populated. We have a list of complaints that have been added for us when we set up our electronic health record in the past. So we can pick, you know, valvular heart disease is often one that we see. When we double click on valvular heart disease, we can go through and add whether or not the patient's having complaints, if they've been in the emergency room. If you click on these top buttons, it populates or clicks no to all of these symptoms down below here, or we can go and add one or the other into the reason for visit or the chief complaint. Exercise capacity, prior medications, whether or not they're following a proper diet, overall health impact, diagnostic procedures. So we can click on everything, or we can go down here to the note, and we can add our own information. So now we have the reason for visit populated. You can click okay, and now it shows up underneath here. Maybe we want to add another reason for visit, so we can click on syncope. Again, we can add information concerning syncope, and this will populate down here as well. Under review of systems, we can have our review of systems pre-populated for us. Our different providers are listed under here, but we can also go under each one underneath as well. So for instance, you can click on general. If we want to highlight the abnormality in the review systems, you can click the exclamation point. You can see below here that it keeps bolding or unbolding, whether or not we click on the exclamation point, if it's present, and then you can click on the pencil here to add. And now it shows up in parentheses if you add a note under that section as well. Fortunately for us, most of the history is filled out by our staff, but these will usually be ordered by the medical assistants. So this is a basic overview of how to enter the reason for visit, the review of systems, and to review the history within the electronic health record. And then physical exam and vitals can be added as well. So here we want to say maybe the patient's 165 pounds, height 65 inches, 133 over 67. And again, now we've added in to our vital signs as well.