Family Physician HR. Electronic medical records and Family Physician HR

EZChart offers a wide variety of features. These Take a Tour provide step-by-step instruction for using many of the features in EZChart. Use the links below access a Tour of your choosing. Use the links above to quickly move to categories of Take a Tour in the index.

CHARTING ONLY THE "ATYPICAL" OR PATIENT-SPECIFIC. Use "TYPICAL" template text to document the office visit, customize it with patient-specific.

TYPICAL medical templates include TYPICAL progress notes with typical complaint & typical normal or abnormal examination, and ICD-9 code, CPT codes; TYPICAL complaints; TYPICAL physical findings or exams. (go to top)

· First step: Search Patient, or Add New Patient. You must have patient on file before add a progress note.

· Third step: Select either Office Visit or Quick Chart on the left side panel, and then select one of the 100 Common Diseases and follow instructions.

1. Select Quick Chart and a disease from 100 Common Diseases.
2. First screen: Review, edit and add Complaint, Physical Exam.
3. Second screen: Edit Diagnosis, ICD-9; CPT codes, Treatment Plan
4. Click “Save”, then “Generate Progress Notes”, and or “Download”, and finally print Prescription & Progress Note.

1. Select Office Visit and select a disease from 100 Common Diseases
2. Complaint Subjective: Review, edit and add any complaint.
3. Make your choice to include or skip any of the following section: Personal History, Past Medical History, Family History, Current Medication, Review of Systems, Exam Objective, Hospital/Treatment Course, Diagnosis & CPT, and Treatment Plan.
4. Exam Objective: Review, edit and add any Exam
5. Diagnosis: The principal diagnosis and ICD-9 come with the template. You may add Diagnosis or ICD-9 Codes.
6. Procedure & CPT Code.
7. Treatment Plan & Write Prescription.
8. Click “Save”, then “Generate Progress Notes”, and or “Download”, and finally print Prescription & Progress Note. (go to top)

This site is intended for physicians and healthcare professionals. Click on “Become a Member” then fill in the registration form, and select your own user-name and password.

The business name will appear on the top of your home page, progress note, and prescription. (go to top)

Immediately after “Become a Member”, you may login using user-name and password. Remember user-name and passwords are case-sensitive. You are ready to use EZChart for your progress note. Please be patient with your first 3-5 charts. After that, we are certain that you will finish a perfect progress note and an error-free prescription in 2-5 minutes.

Please take time to explore our 1,000 typical medical templates. Example: When you are at “Office Visits” or “Quick Chart”, scroll down to the end of panel to see what are in there. When you are at “Complaint”, scroll down to the end of “Default Complaint” panel to see what are in there. When you are at “Review of System”, scroll down to the end of “Default ROS” panel to see what are in there. When you are at “Exam Objectives”, make a choice at “Select a System”, then scroll down to the end of panel to see what are in that system.

At 100 Common Diseases screen, you will see on the left side panel three groups: New Office Visit, Quick Chart, Health Record Summary, and Document Storage, including Lab, XR/EKG, Hospital, Consult, and Mis.

On the top menu bar, you will see Home; Patients; Patient Notes; My Templates; My Profile; My Database; Customer Service, Logout. Make your selection. Customer Services give you links to Tech Support, Billing History, and FAQ.

Move cursor over each link, you will see drop-down list. In Patients, you see Search Patient, Add New Patient (go to top)

If you like to change or update your personal info, business info, upload and change your logo, and photo, upload your e-signature, and change the website theme, your password, click My Profile, and make your change in Update My Profile.
Your name and business name, address, telephone number, license numbers will be on your prescription and your progress note. (go to top)

Office Visit includes a unique feature 100 Common Diseases. They are 300 complete progress notes for 100 common diseases you may see in your primary care office.

Each disease comes with typical subjective complaint, typical physical examination, ICD-9 & Diagnosis with brief Disease Discussion, and Patient Follow Up guidelines. Make any change in any prebuilt text.

You may search for a disease, by first enter the “system”, such as PUL for pulmonary, then scroll down from that highlight group. You may scroll down until you find the disease. Click “Next” or double click on the selected disease.

100 Common Diseases are organized by system, then diseases.
System includes ALL for allergy, BREAST, CVS for cardiovascular, ENDO for endocrine, ENT, EYES, GI, GU, INF for infection, MUS for musculo- rheumatology, NEU for neurology, NORMAL for normal physical exam, PULMO, SKIN, STD.
To search: First: Select system. Second: Select disease.

Case study: Patient with main problem: Asthma.
What to do: Enter PULMO in search. Scroll down until Asthma. Click next. (go to top)

Each Quick Chart progress note comprises of two pages or two clicks. The first “click” is typical progress note with typical complaint, typical physical examination, the second “click” is for diagnosis with ICD-9, and treatment plan, follow up.

Click Quick Chart. Select a Disease. Review and edit the text. You may add Complaint from drop-down list of Add Complaint. You may add any physical examination, by first “Select a System” from drop-down list, and then under “Select & Click”, select the exam that is matched to your patient’s condition. Click Next to diagnosis, add test and XR, and treatment plan. (go to top)

Each Office Visit Quick Chart template comes with a typical complaint. Review template text, and then edit it with patient-specific. You may add additional complaint from “Default Complaint” or enter your own text.

To add additional complaint, from “Add Complaint”, scroll down until find the desired one.

Case study: Patient with main problem: Asthma. This patient also complaints of dyspepsia.
What to do: From “Add Complaint”, scroll down until GI Dyspepsia Click “Add Complaint” after you have reviewed and edited the additional complaint. (go to top)

After Complaint, make your choice to include or skip any of the following section: Personal History, Past Medical History, Family History, Current Medication, Review of Systems, Exam Objective, Hospital/Treatment Course, Diagnosis & CPT, and Treatment Plan.

Fill in all blanks if you need to. If you already have all patient info in Health Record Summary, click “Insert this section into progress note” will save time. (go to top)

“Select a Review” from Default ROS. Edit, then click Add. We group ROS first group is Adult, second is for Infant, the third is for Pediatric.

Case study: Patient with main problem: Asthma, Dyspepsia.
What to do: You want to add some ROS: Select and add ROS General, Chest & Lung, and Genitourinary. (go to top)

To edit, select the system exam, make any changes with patient specific, then “Save Edit”.

To remove any system exam in prebuilt template, select the system, click “Remove”.

You may add additional abnormal physical finding by “Select a System”, then select the exam you want, preview & edit, then click “Add & Replace Normal”

Case study: Patient with main problem: Asthma, and dyspepsia. You find the patient has psoriasis lesions on back and elbows.
What to do: From “Add an Exam”, select SKIN. Select SKIN Psoriasis. You may enter the location of skin lesion. Click “Add & Replace Normal”. (go to top)

The Office Visit comes with the principal diagnosis & ICD-9. You may add additional diagnoses & ICD-9. Select A-Z on left panel. On right panel, you will see all diagnoses starting with same letter. Make your choice. If you don’t find one, you may write your own diagnosis by click “Write New Diagnosis”. Fill the pop-up window with diagnosis, and/or ICD-9, and then click “Add”.

Case study: Patient with main problem: Asthma, dyspepsia, psoriasis
What to do: Click D, then dyspepsia. Click P then psoriasis. (go to top)

First select or click a category from drop-down list, then click on one of the procedure. If you don’t find one, you may write your own procedure and CPT code by click on “Write New CPT & Procedure”. Fill the pop-up window with procedure, and/or CPT, and then click “Add”.

Case study: Patient with main problem: Asthma, dyspepsia, psoriasis
What to do: Click E/M Office, then 99203. (go to top)

You may select as many drugs to prescribe, as you like. Select the brand name, dosage, frequency, and quantity, the click “Add Selected”. Remember all medications in our database are listed first with brand name. If you don’t find one, you may write your own prescription by click on “Prescribe New Drug”. Fill the pop-up window with name, dosage, frequency, amount, and then click “Add”.

Drug interaction, side effects and precaution will pop up each time you write a prescription.

TIP: For any combination drugs, in liquid form, such as Novahistine DH, in dosage, you may use word LIQ or SYRUP; in tablet form, such as Entex PSE, in dosage, you may use word TAB.

Case study: Patient with main problem: Asthma, dyspepsia, psoriasis
What to do: Example you prescribe Advair, and Tagamet. (go to top)

The Office Visit comes with a brief disease discussion. You may ignore this Section or select additional patient education. Fill the Follow Up Instruction.

Case study: Patient with main problem: Asthma, dyspepsia, psoriasis
What to do: Click “Save”, then “Generate Progress Notes”, and or “Download”, if you want to download the prescription and progress note into your office computer. (go to top)

By pressing "Generate Progress Notes," the Progress Note and Prescription window will appear. If you want to download the Progress Note and Prescription into your office computer, click “Download”.

The Prescription is ready to print. You may want to edit REFIL, LABEL and DO NOT SUBSTITUTE. Click Print. Then close the prescription window. It will display Progress note window.

Case study: Patient with main problem: Asthma, dyspepsia, psoriasis
What to do: Click “Print”, and the close the Prescription window. (go to top)

Case study: Patient with three problems: asthma, dyspepsia, psoriasis
What to do: Click Print", then close the Progress Note window. You are ready for another Office Visit.

You’ve done! Congratulation! A Perfect Progress Note and Error-Free Prescription. (go to top)

If errors are found after a note has been signed, saved and stored, a new addendum note can be composed containing an explanation of the errors and will be appended to the original note. This is similar to the way one would correct a traditional paper record that has already been signed.

First “Search Patient”, then click “Office Visit History”. Simply go to the note you wish to correct, check the Addendum, and write your correction. Due to HIPAA regulations, the original text will be retained as an inactive file which can be recovered if needed in the future, and the corrected text will become the Addendum note. The date of the correction will be recorded and saved as well. This provides an audit trace of any changes made to medical records. (go to top)

First Search Patient or Add New Patient. When you find the patient, click Upload. You will see Upload Panel. With Upload From, select where you have stored the document to be uploaded, such as drive C, drive A, Z drive… With Upload To, select the section in patient chart you want the document to be in, such as Lab, XR/EKG, Hospital, Consult, Mis. Click “Add”.

First, you may use scanner to scan the document to one of your drive, and do upload from there.

Tip: To save time and space, you may enter a brief summary of Lab, XR, EKG, Hospital, and Consult into Description section in Upload panel, instead of scanning the whole document. Example: Instead of the 2 page MRI report of the brain, you may enter: Date 12/22/2003 MRI of brain: Normal. (go to top)

It gives you all essential patient information, every time you open a patient chart.

For your convenience, click “Insert this section into progress note”, that section will be copied and inserted into appropriate section in your active Office Visit. (go to top)

Medical records are signed by the healthcare provider to establish a given entry as legally complete. Unsigned medical records are considered to be drafts. Once a record is saved and signed, it cannot be legally edited thereafter. All corrections after signing must be in the form of an appended statement. This requirement also applies to electronic records.

Electronic signatures are created when the user enters a unique code, or password that verifies the identity of the signer, thus creating an individual "signature" on the record. Signature lines generated in these media are prefaced by a statement such as "Electronically authenticated by John Doe, MD on (date and time) or by a scanned signature. To upload a scanned signature, go to “My Profile”, scroll down to “Upload Scanned signature”. You must have your signature scanned into your computer, drive C or A.

To digitally sign a note, simply click on the red "Sign It" and enter your password one more time to confirm. This will convert the note to a read-only status and will prevent further editing. The identity of the person signing the note, as well as the date and time of signature will be recorded in the database. (go to top)

The monthly subscription fee is based on your database size. To keep your subscription fee at $39, please do the following: Check “My Database” to see how much space you have used, and keep your database under 10 MB.

Maintain a hybrid system. A hybrid health record is a system with functional components that include both paper and electronic documents, use both manual and electronic processes. For example, progress note, patient info and health record summary, lab, and x-ray results might be available electronically, whereas hospital record, consult report, ancillary care, provider information, graphic sheets, and doctors' orders remain on paper. Other health information may be maintained on various other media types such as film, video, or an imaging system.

To keep the subscription fee down, download and remove old records, such as progress notes, lab, XR, EKG, hospital and consult reports into your office computer. (go to top)

You can add your own templates, modify or customize our templates, from complaint, exam, to a complete progress note. All customized templates will be saved under “DOCTOR XX”.

To customize or add an office visit for your personal use, you will need text or making changes in the following sections: Complaint, Exam Objective, Diagnosis & ICD-9; Patient Education Discussed.

· Next select “Exam Objective” to customize the exam objective section, by adding, delete or modifying any sectional exams.

To customize or add a Complaint Subjective, or an Exam Objective for your personal use, click Complaint or Exam from My Templates, then make any change from our existing templates, or add your own new text. (go to top)

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