 |
 |
STEP 1 - PATIENT HISTORY
The Patient Information Form is completed by each new patient along with a Supplemental History Form for the particular joint(s) the patient has a problem with. The Patient Information Form collects information for billing and information about the patient's general medical history. The Supplemental History Form addresses the specific orthopedic condition. Together, these forms obtain a complete medical and orthopedic history. These forms are available pre-printed and color coded or they can be printed on your printer.
The patient can fill out the form in the office before their exam or if the form is mailed to them, they can fill it out at home. Alternatively, if you purchase the History Makar system, the patient will input their information directly into the computer. This data will automatically be transferred into the Benevolent Dictator database.
The physician reviews the medical history information and adds notations. Dictation of the medical history is not necessary. A comprehensive Medical History Report will be generated by the computer.
STEP 2 - PHYSICAL EXAMINATION AND X-RAY EVALUATION
The Physical Examination Form and X-Ray Evaluation Form are completed by the physician or an assistant. This is accomplished by notations, check marks, circling, and fill-in-the-blanks. Completing this form takes the place of dictating the information.
STEP 3 - REFERRING DOCTOR AND PATIENT LETTERS
At the end of the examination, the physician fills out one Letter Input Form.
The physician has now completed all of his documentation requirements.
STEP 4 - DATA INPUT AND REPORT GENERATION
The form data is input into the computer by office staff. The Benevolent Dictator program has been designed so that the data can be input very quickly. The data is stored in a database so that the information can be easily retrieved at anytime. The computer then generates the following comprehensive narrative documents:
|
|
 |
Patient Information Report (a brief report to be placed at the beginning of their chart) |
|
Medical History Report |
|
Physical Examination Report |
|
X-Ray Evaluation Report |
|
Patient Letter (includes clinical impression, surgical indications, recommendations, post-op activities, warnings, prognosis, etc.) |
|
Referring Doctor Letter (gets data from the same form used for the Patient Letter.) |
|
Composite Letter (summarizes history, physical, x-ray, and patient letter. No additional data entry is required for this report.) |
Multiple copies of these reports can be printed and sent to the appropriate places. The Patient Letter, Referring Doctor Letter, and Composite Letter can be addressed to anyone you desire. For example, you may want to send the Referring Doctor Letter to the referring doctor and to the patient's insurance company. The computer will automatically word each letter appropriately.
STEP 5 - SURGERY DOCUMENTATION
After surgery, the Surgery Form is immediately completed by the physician or an assistant.
STEP 6 - DATA INPUT AND REPORT GENERATION
The completed form is returned to the office staff and input into the computer. A comprehensive Surgery Report is then generated and a copy is forwarded to the hospital for their records.
After the Surgery Form is input, the Composite Letter mentioned above will also contain a summary of the Surgery Report. This letter is generated from the data that has already been input. No additional dictation or data entry is required from the office staff. This Composite Letter can be sent to the referring physician or anyone else you want to send this information to.
|
|