Electronic medical record databases in a nutshell
The Chart Links electronic medical record for physical therapy and occupational therapy services contains about 20 databases in the work flow application that make it easier for therapists to document and track patient records. Each patient chart also is in a separate notes database of the medical record and is available for staff review in multiple locations.
Cincinnati-based Children’s Hospital Medical Center, which helped develop the software, offers descriptions of the work flow database. Here is a partial list:
• Patient directory: This is a comprehensive listing of patients that can be viewed by patient name or medical record number. All demographic patient information is kept here, such as insurers, primary physician, and specialists.
• Referrals: Containing all patient referrals, the electronic referral uses information from the physician’s referral, which is scanned into the database for easy viewing and access.
• Evaluations: The occupational therapy, physical therapy, and speech pathology evaluation databases feature standardized evaluation forms. Therapists also can create individualized evaluations or modify existing ones. They compose reports by choosing lists of keywords in each evaluation section and using open text fields to type information not found on the keyword list. Once the form is completed, it’s automatically reformatted into a professional-quality, typed document. The forms can be faxed automatically so the physician can receive the evaluation report within minutes of signing the document.
• Treatment documentation: This contains treatment plans and progress summaries for all patients. Information comes from the referral, and long-term goals are selected from a large goals database, which allows therapists and administrators to monitor incomplete documents.
• Progress note/charge: Therapists compose daily progress notes and charges. They charge each patient by choosing the appropriate charge item and number of time units, and the system automatically calculates the charge. All charges appear on a billing log and can be printed or automatically sent to the hospital’s billing system.
• Goals: This contains a list of long-term goals, which can be used when creating treatment plans. Therapists can add or delete goals at any time.
• Home programs: Therapists use this to create instructional documents for patient education. There are more than 150 exercise programs, including photographs. Home programs can be created and listed by title, number, and category.
• Current appointments: This contains all patient appointments and can be viewed by date, therapist, and location.
• Appointments history: This contains a listing of all previous patient appointments and attendance status, which also can be viewed by date, therapist, and location.
• Personal mailbox: Each therapist has a personal mailbox that provides scheduling and e-mail capabilities. All appointments also are located in current appointments database.
• Letters: This contains forms to write letters to physicians, insurance companies, or patients. All letters inherit the appropriate demographic information, and those written to physicians and insurance companies can be faxed on-line.
• Insurance: This includes all insurance companies and plans to which patients subscribe, including information specific to each company’s requirements. It also contains the patient’s authorization history.
• Physician: This contains all referring physicians, their addresses, phone numbers, and fax numbers. It’s available by physician name, practice name, specialty, or city.
• Code: This contains ICD-9 diagnostic codes with the appropriate CPT codes and charges.
• Resource/school: Containing a list of community and professional resources, this reference database allows access to commonly used information, such as community services and agencies.
• Employee: This includes pertinent information regarding employees, students, and applicants, including employees’ status, rate of pay, years of experience, licensure status, continuing education activities, and other key employee data. Supervisors can monitor requests for time off, attendance, and work schedules.
• Policies and procedures: This contains all departmental policies and procedures, sorted by title, category, number, and codes from the Joint Commission on Accreditation for Healthcare Organizations in Oakbrook Terrace, IL, and the Commission on Accreditation of Rehabilitation Facilities in Tucson, AZ.
• Budget: This can track all expenditures, and it provides information on the budget’s amount, expenditures, and account balance.
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