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Re: keeping electronic records, rectals and attorneys From: Anil Singhal, MD (anil@versaform.com) Sat Dec 27 09:55:15 1997 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Roger Klam, M.D.: "Re: Health Insurance/HMO's" Previous message: Mariela Nieto: "Re: Intractable bleeding" In reply to: Richard Lowensohn: "Re: record keeping, electronic, for OBs?" Having been an administrator for a group of 31 Ob/Gyns, I can understand your concern that the system could document a Rectal exam "Normal", if you so desired it to, even if there were no rectal exam done. Realizing so many practice styles exist, most of which are valid, I made this system lead in flexibility. The templates are modified with two or three mouse clicks to reflect your care exactly as it happened ( like dictation or writing ). There are several ways to modify the note and the template depending on your style: 1) "I rarely do rectals on patients presenting with PMS" The solution here is to open the PMS template, delete the line "rectal exam" and save this modification. Choice 2 would be to de-select a preprogrammed answer for rectal exam so the system would require you to answer this area even if you pressed the "use defaults" button. Thus, for each patient you would either select "not done" or any response from the list (or can freely type). Alternatively, you can let the note be created with the "rectal exam normal" comment, then move your mouse into the note and delete that line. 2) "I rather say 'rectal exam without masses, confirms pelvic findings, and occult blood negative'" In this situation, you just modify the default answer to what you feel is appropriate. It now reflects your personal style as a traditional note would. A major idea with this system is that the supplied templates are a solid foundation for most practices. But, with individual styles and group requirements for documentation, the templates, the pick-lists, and the notes are modified by a few mouse clicks. I feel it gives you the flexibility of dictation/transcription with out the cost and hassle. I think seeing the demo CD-ROM will be revealing. Please feel free to contact me if there are further questions. Anil@versaform.com At Thu, 25 Dec 1997, Richard Lowensohn wrote: > >I noticed that your system "defaults" to stating that things are normal. Have >you verified that this will hold up in court? What if someone did the exam in >your example page, but didn't do a rectal exam? Will it still say "normal"? > >-- >Richard Lowensohn MD >Oregon Health Sciences University >lowensoh@ohsu.edu > >>>> "anil" 12/24/97 10:43am >>> >> >>You may have hear of our system. An Ob/Gyn in Oregon just purchased it. >> >>I have been intimately involved in the design of an electronic record >>keeping system specifically for Ob/Gyns ("VersaForm CPR, Ob/Gyn"). >> >>The system has a large set of templates geared for gyn, >>ob, and basic primary care, besides the basic portion of >medication/allergies/CPT&ICD9/Lab tracking >>and Rx writing, >> >>The note-taking templates are easily modified and using them requires scant >computer skills >>(you do have to know how to use a mouse!) >> >>We have a demo CD-ROM which we can send on request and >>our web site is http://www.versaform.com. >> >>Anil Singhal, MD >>VersaForm Systems >>Campbell, CA 95008 >>800/678-1111 >>408/370-2662 >> >>>Date: Thu, 18 Dec 1997 14:26:15 -0600 >>>Reply-to: ob-gyn-l@obgyn.net >>>From: sucheta@juno.com (Dr Sucheta Sharma) >>>To: Multiple recipients of list >>>Subject: record keeping, electronic, for OBs? >>> >>>A colleague of mine said she heard of a electronic medical record system >>>for OB/GYNs but doesn't have any details. Anyone using such a system? >>> Feedback? >>> Recommendations? >>> Searching the Web I only found general care systems. >>> >>>thx, Sucheta. >>> >>>Sucheta Sharma, MD > -- anil@versaform.com http://www.versaform.com Next message: Roger Klam, M.D.: "Re: Health Insurance/HMO's" Previous message: Mariela Nieto: "Re: Intractable bleeding" In reply to: Richard Lowensohn: "Re: record keeping, electronic, for OBs?"

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