Medical Records

For years doctors have dreamed of giving their medical records a professional look without effort. Today we have taken that dream and made it a reality. The M.S. Group has developed a method of capturing exam information that is effortless and at the same time produces a professional comprehensive exam record. The system is easier to use than pen and paper. During the design phases of Medical Records, several different types of input devices were tried, which included the keyboard, mouse , and touch screen. Touch Screen provides an expeditious means of data entry and is the preferred method to input diagnostic information in a darkened exam room.

Medical records consists of various parts called "elements". Examples of an element would be a Cover Test, Slit Lamp or Fundus Exam. The display of sequence of these elements are set-up by you in a script file. You can have a number of different script files. For example, you might have a script file for your staff to enter the patients history and complaint; another script file for a technician to record the results of an Acuity Test, PD readings, Blood Pressure, IOP, etc.; finally a script for the doctor such as Slit Lamp, Fundus Exam, Diagnosis, and Treatment Plan. You might have one script for contact lenses and another for follow up contact lenses check. The system allows for 30 different scripts.

All library files can be added to updated or deleted. They refer to every part of the system. Many of the files can be modified dynamically during the exam.

The system allows you to preset common Treatment Plans. You simply key in what you most commonly Prescribe as treatment. During the exam you would select the treatment plan and then the system allows you to modify the treatment through a word processor. An example would be, "removal of foreign object". In the verbiage you might say that it was removed with a spud or needle. If you used a spud you would delete the word "needle" or vice versa. This allows you to quickly and articulately describe your treatment. You have the availability of 1000 lines of notes to describe your treatment. There is a script to allow you to set up the sequence of exam elements you want printed. There are also script forms that can be set up for various types of letters; to the patient or referring doctor, etc.

As you acquire multiple records on your patients, use our "Compare" function. This allows for test results to be viewed chronologically on one screen for efficient evaluation. Compare IOP readings on your glaucoma patients by date, time, and readings to evaluate treatment and changes in their eye health.

The system was designed so that the doctors subjective exam information is picked up by the Practice Management Software which automatically generates the prescription and eliminates the requirement to re-enter the diagnostic data. This information becomes a permanent part of the patient file. Accurate records are more important as the "Outcome Based Reporting" becomes required. Several states and insurance companies have adopted standards for the completeness of medical examination records. Audits by Medicare and other government organizations are a reality and fees which were charged but not documented are being charged back to the doctors which results in lost revenue.

As quoted by Medicare "If it ain't in your medical records, it ain't been done".

Legibility is a prime requirement. In offices where there is more than one doctor, legibility in patient records is at hand when one doctor is required to see another doctors patient. With our system, the results of each part of the examination is clear and concise.

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