Dairyland Healthcare Solutions announced the introduction of a new ambulatory electronic medical record (EMR) application, Physician Practice Documentation. The application provides physicians the ability to electronically document patient encounters. The application enables users to document a patient’s visit, automating the tasks associated with charting patient exams and assessments, resulting in a secure electronic medical record.

“Our customers serve their communities through multiple care settings. Physician Practice Documentation extends the electronic medical record into the ambulatory environment,” said Nancy Beavin, Vice President of Clinical Solutions at Dairyland. “Further, the application’s broad set of features and functionality provide a variety of benefits including the potential to reduce costs, increase revenue, improve administrative and clinical staff efficiency, and enhance patient care and safety.”

At the core of the application is its functionality for automating the process around a patient’s assessment and diagnosis. Utilizing the Subjective, Objective, Assessment and Plan (SOAP) methodology, documenting a patient encounter is a simple process of selecting the appropriate information, as the interface is designed to allow users to focus on data selection instead of data creation. Throughout the encounter patient information including: demographic; medical, surgical, social and family history; medications; allergies; test results and immunizations, is immediately available online to support decision making. As the user progresses through the encounter a detailed visit note is automatically created. When the encounter is complete the application suggests an E&M code based on visit documentation. Once finalized, the visit note is immediately available in the patient’s electronic medical record.

Physician Practice Documentation incorporates familiar Windows® functionality for intuitive, user-friendly navigation and has been designed to follow the workflow of a patient visit, automating tasks and streamlining processes. Developed with flexibility in mind to meet the varying needs of practices and users, practices can easily customize components of the application - such as templates, select lists and data fields - to meet the organization’s requirements and individual user preferences.

Finally, Physician Practice Documentation has been developed on the same architecture and is tightly integrated with the Dairyland Healthcare Information System. The integrated applications together create a single, comprehensive electronic medical record for each patient across the care settings within the healthcare system - Hospital, Clinic, Long Term Care and Home Health.