The Medical Office Records

Electronic health records (EHR) represent the next step in the evolution of medical software as it relates to patient care. While practice management systems are capable of increasing overall productivity and improving bottom line cash flow, the integration of EHR software expands on those benefits by further enhancing office workflow, minimizing paper-based redundancies and automating the selection of diagnosis and CPT codes based on chief complaints.

The Medical Office Records is a comprehensive, yet easy-to-use electronic medical records software for healthcare providers of any size or specialty. The Medical Office Records does more than just log patient information. The software is designed to follow the flow of your patient visits, from chronicling patient histories and previous encounters to establishing new examination records via a series of provider-specific templates.

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How The Medical Office Records Can Benefit You

Increases the time providers can spend with patients and automates their visits.

• Minimizes the amount of paper records your office is required to keep on hand in order to maintain detailed patient histories.
• Maximizes revenue and reduces the chance of manual coding errorsby suggesting an E&M coding level.
• Vastly improves turnaround time for patient visits and retrieving lab results.
• The software's customizable interface can be adapted to your personal style, enabling you to provide a more efficient standard of care.
• Significantly reduces or eliminates transcriptions costs.
• Interfaces with a number of practice management systems, allowing you toeliminate redundant data entry.

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Office Workflow Features of The Medical Office Records

Core Functionality

• Easy navigation menu is designed to increase usage speed while streamlining the data recording process
• Interfaces to a number of external software packages, including practice management systems, transcription software, imaging systems and lab information systems
• Intuitive sentence builder allows doctors to personalize chart notes and significantly reduce - or even eliminate - the need for transcription
• Identify missing, incomplete or unsigned progress notes
• Customize the order and sentence structure of your question/answer templates
• Built-in security allows access rights based on customizable user roles
• Password-protect sensitive areas, such as automated signatures for prescriptions
• Communicates with office management software to simplify scheduling and eliminate duplicate of patient demographics

Office Tools

• The Tracking Board consolidates information from many multiple sources to a single screen. From one window physicians can viewing messages in their inbox, follow patient flows through the clinic, sign chart notes and more
• View, print or e-mail chart summaries or entire charts for any patient
• Record and sort transcriptions by the date of upload, date of last edit, facility, physician and/or document type
• Tasks can be assigned to office staff, tracked and marked off when completed
• The software includes internal messaging capability
• Use of voice recognition software, such as Dragon Naturally Speaking, available throughout the entire encounter or SOAP Note.
• Handwriting recognition available throughout the encounter or SOAP Note

Billing & Coding

• Automated E&M Coder calculates optimal coding levels, resulting in less manual coding errors, more accurate and justifiable billing, and the practice receiving full payment for services rendered
• Includes ICD-9 and CPT codes, as well as the ability to add modifier codes and custom alternate descriptions or abbreviated descriptions
• With a single click,information from the completedSOAP note is sent to the practice management portion of the program. Theclaim isautomatically generated, and sent to the insurance queue for payment

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Patient Care Features of The Medical Office Records

Encounter / SOAP Notes

• Create tailored plans of care for each patient based on their medical histories and current encounter
• Progress notes accept multiple forms of data input, including user-defined terminology, manual test entry and dictation
• Additions and edits are automatically updated into other sections of patient chart
• Insert previous progress notes into the current note for cases of recurring ailments
• Patients can complete some sections of the encounter note in the physician offices prior to meeting with the provider
• Software creates audit trails of patient data access by time / date and username
• Define and customize new templates or edit existing ones. The template changes can be made permanent or affect only the patient at the point of care
• Customizable for each physician by chief complaint
• Generate referral notices from SOAP note
• Preview notes prior to completion
• Ability to import patient questionnaire into notes

Differential Diagnosis

• Customize the software to automatically designate certain procedure and CPT codes for a specific diagnosis
• Identify lab tests and prescriptions that each physician commonly orders when dealing with a particular diagnosis
• Add or delete an unlimited number of ICD-9 codes, CPT codes, lab tests and medications to be associated with any diagnosis
• Document one or more differentials associated with a diagnosis

Patient Administration

• View side-by side comparison of patient's historical vital signs and statistics
• Upload and manage a variety of patient-oriented documents such as scanned images, voice files and transcriptions
• Set recall notices for preventive care and patient health maintenance
• Attending physician can assign electronic signature to progress notes, prescriptions and referring letters.
• Output patient charts to consulting physicians
• Provide and track distribution of educational materials to patients
• Produce a variety of customized documents utilizing information from the patient's database

Consultations and Laboratory Testing

• Order tests, physician consultations and surgical procedures directly from the patient chart
• Track outstanding lab orders
• Flag abnormal lab results
• Graphically display lab results
• Import lab data using HL-7 compliant format

Prescription Writing

• Write multiple prescriptions for each patient
• Utilizes the Gold Standard Drug Database containing almost 35,000 drugs with informative consults
• Drug interaction analyzer identifies potential drug-drug, drug-allergy and drug-pregnancy conflicts
• Electronically send prescriptions to specific pharmacies via a secure connection
• Multiple prescription templates include a description of the medication, dosage recommendations, patient education forms, drug ingredients, possible medication alternatives and more

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Document Management Features of The Medical Office Records

Document Management

• Include personal notations for all documents managed by STAR^® (STorage And Retrieval)
• Images can be search for based on a variety of fields, including patient or document name, scan or index date, text or folder search, or fuzzy search, which tries to match characters if letters are not perfectly readable
• Files can be indexed by patient number and date for faster retrieval
• Manage images using sub-folder hierarchy
• Controls storage and access to new and legacy documents
• STAR integrates with The Medical Office Records to allow for easy document management and image scanning

Image Scanning

• Scanned documents can be automatically indexed based on templates using optical character recognition (OCR)
• STAR utilizes an office workflow structure when dealing with new images, from document upload to patient assignment to naming and indexing to confirmation
• Documents can be stored in multiple file formats, including JPG, TIFF and GIF
• Images can be scanned as color or grayscale pictures, black & white pictures with text or based on a customized setting
• All new scans are automatically filed in a user-defined default folder to prevent accidental indexing

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Optional Companions to The Medical Office Records

The Medical Officeuot - Practice Management

The Medical Office is a powerful medical management and billing software for healthcare providers of various specialties and sizes. Easily manage patient data, process electronic claims, schedule appointments and produce over 325 customizable reports in one comprehensive software package. An ASP version of the system is also available.

SofTalk Link Engine

The SofTalk Link Engine enables The Medical Office to bi-directionally interface with third-party software applications. Each link engine module runs in the background of your SoftAid software, and provides summary detail for applications such as Quickbooks, Peachtree, Crystal Reports and any of our strategic partners' programs. Link Engine modules can also be developed for any other third-party software, as needed. This seamless operation eliminates the need to manually export data and does not conflict with any other computerized operations.