Entering Notes in the Electronic Medical Record

eVetPractice offers many different ways to enter your medical record notes into the system for each patient. There is no one right way, but this article gives an example on how to use each feature.

NAVIGATING TO THE MEDICAL RECORD

There are many ways to access the medical record, but the two most common ways are through the quick search feature and directly through an appointment:

Quick Search

  • In the upper right corner of the screen type in either the patient's or client's name. If you type in the patient's name you will see a list of all patients with that name and their owner listed to the right of the name. If you type in the client's first or last name you will see a list of all their pets below the clients
  • Click on the patient's name to go to the medical record.

Appointment

  • If you have an appointment for the patient, left click on the appointment

  • Click "Go To MR" to navigate to that patient's medical record. Please note this will only work if you have assigned the appointment to the patient. For more information on creating appointments please see this article - Scheduling Appointments in the Calendar

Once you are in the medical record you will see the patient highlights at the top of the screen:

Keep scrolling down and you will see the beginning of your medical record. Please note there are 3 different medical record views - View by Date (most common view used), View by Groups, and View by Date with Details. You can experiment with different views, but this article will focus on the View by Date view:

Numbers 1 - 11 will be explained over the next few sections.

 

1. REASON FOR VISIT

It is recommended to have a reason for visit for each time you see a patient. There are 3 ways this can be entered:

1. When a patient is checked in (recommended)

When a client arrives, you have the option to check in that appointment and copy the visit description to the medical record as the reason for visit by changing their Visit Status. For more information on Visit Statuses, please see this article - Configuring Visit Statuses

CHECKING IN A CLIENT FROM THE CALENDAR:

  • Left click on the appointment you wish to check in
  • Click either “View or Edit”

  • Change the visit status to “Check In” (or whichever visit status you have configured to copy the visit description to the reason for visit)
  • Click Save at the bottom right

  • This will place the client and patient on the whiteboard, print the check in sheet, and copy the visit description to the reason for visit field in the medical record if you have configured your visit status to do so..

2. When you create the appointment

This is used by many mobile vets who do not necessarily have a check in process and would just like the option to copy the visit description to the medical record when they create the appointment. Please note that if you do this and then cancel the appointment, it will not remove the reason for visit from the medical record. For this reason, Method #1 is recommended.

 

If the box outlined above is checked and the patient is assigned to the appointment, the appointment description will be copied over to the reason for visit as soon as you click Save.

3. Enter the Reason for Visit manually in the EMR

If you go to a patient's  medical record and there is no reason for visit, it is because either the patient was not checked in or because no appointment was ever made for them. If so, you can manually enter the reason for visit. Simply click on Reason for Visit (Number 1 in the picture above) and the below screen will appear:

 

2. HISTORY FORM

We often see that before the veterinarian goes into see the patient, an assistant or technician comes in to take a history on the patient. This person can use a history form to collect data. These forms are completely customizable so you can assure that the correct questions are getting asked each time. For more information on creating and editing History Forms please see this article - Creating and Editing History Forms

To choose your form click on History Form (Number 2 in the figure) and choose the appropriate form from the list and then click Add. Also note that if you clicked on "Save and Add History" in the Reason for Visit section above, it would also take you to this screen.

Once you click "Add" your form will appear:

 

3. EXAM FORM

Some practices choose to have separate history and exam forms, while other like to create one exam form that also has a history section. This is especially helpful if the veterinarian on duty is responsible for taking the history and conducting the exam. Exam forms are also completely customizable - Creating and Editing Exam Forms.

Exam forms work just like history forms. You will need to click on Exam Form and then select your exam and click "Add" as described above. Here is a sample exam:

Once you are done with your Exam form, click Save.

 

4. DIAGNOSIS

Once you have entered your notes into your exam form, you have more options for adding information into the electronic medical record. The Diagnosis section allows you to search through pre-loaded diagnosis codes or free hand your own diagnosis:

In the "Create Master Problem" check box highlighted above, you can enter whether or not this is a master problem that needs to be monitored because it is chronic, severe, etc. For more information please see this article - Monitoring Ongoing Problems and Medications

 

5. TREATMENT

When you think of Treatments in eVetPractice, think "this is where I go to do my charges." This is where you will assign billable items to this patient. When you click on Treatment, the following screen will appear:

 

Once you add a billable item, you can click on it to change the following options. Please note that the Rx Details will only show up if the inventory item is marked as "Is Dispensable."

For more information on treatments and invoicing, please see the following articles:

 

6. DOCUMENT

Here you can upload documents directly to the electronic medical record. When you click on this item the following screen will appear:

 

7. PLAN

The optional plan section will allow you to enter additional notes into the EMR. Typically this section is not necessary when you are entering this information into an Exam Form.

 

8. MEDICAL RECORD NOTES

This is a section where you can add additional medical record notes. Typically this is used if you are not using history and/or exam forms. The form is identical to the Plan section described above.

 

9. CLIENT COMMUNICATION ENTRY

Here you can add communication with the client directly to the medical record. For example, if they call you and let you know that the dog is having an issue and you recommend they come in if it is still going on tomorrow, you can enter that in this section so you can mark what your recommendation was. When you click on this item the following screen will appear:

  1. Check off that you would like to create a whiteboard entry. This is good if you would like to assign it to an employee for follow up.
  2. Choose which employee you would like to assign it to. If you do not want to assign it to a particular employee you can leave it at "Not Assigned"
  3. Enter the information regarding the client communication. This is what will appear on the Whiteboard
  4. Click Save.

 

10. ADD HISTORICAL LAB RESULTS

Often when a you get a new client, they will have a prior records from a previous clinic. Here you can enter the results of past labs (such as heartworm tests). This section will also create reminders for new lab work if you have a reminder attached to that lab, such as an annual reminder on heartworm tests. When you click on this section, the following screen will appear:

Once you choose your lab and click Save, the system will allow you to choose the appropriate lab form in which to enter the results. Lab forms are customizable so that you can create your own templates for entering these results. For more information on lab forms, please see this article - Creating and Editing Lab Forms

Once you choose your form, it will show up below where you can enter your results:

 11. Anesthetic Monitoring Form 

When you have an anesthetic patient the anesthetic monitoring form can help record pre-surgical medications, induction agents and vitals signs live time before, during and after surgery. 

After clicking the Anesthetic Monitoring Form link the system may prompt for a weight if one has not been entered after a certain amount of time. Click on "Save and Go to Anesthetic Monitoring" and you will be brought to the anesthetic monitoring form.

Or if a weight has been entered recently you will be taken directly into the anesthetic monitoring form.

*Note: To create defaulted pre-meds, induction agents, and emergency drugs and fluids as well as how to use the anesthetic monitoring form please visit the following help article Anesthetic Monitoring Form Set-up and Use

SUMMARY

As you can see, there are many different ways to use the Electronic Medical Record in eVetPractice. Above we outline common uses of the system, but there are many different ways to utilize the EMR. If you have any questions please contact Support, your Sales Account Manager, or your Client Trainer.

 

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