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Informatics

We use GE Centricity EMR software for practice-based learning, population care and evidence-based medicine. We are focused on the development of this technology as a tool for clinical improvement and addressing community needs. As part of our commitment to improving the delivery of health care through the sharing of medical knowledge, we make the following EMR forms available for download.

Patient Instructions/End of Visit Summary

Downloads

Screenshot

Clinical kit

Description

This form is a component of the generic "Concord Office Visit" form that generates a customizable end-of-visit summary.

Purpose

To to meet the needs of each patient while fulfilling the HITECH stage 1 measure.

Ages

This form was created for all ages.

Special Features

  • Allows each office and each provider to include or filter out various problems, medications, lab results and tests;
  • Identifies new or discontinued medications;
  • Includes free-text field for personalized instructions.

References

HITECH stage 1 final rule

Created: 03-01-2011
Last Updated: 06-17-2013

General Office Visit

Downloads

Screenshots

Clinical kit

Description

This is a form designed as an all purpose standardized template to be used by primary care doctors for acute and chronic visits. It attempts to replicate the natural clinical workflow of an office exam. Clinical decision support is embedded throughout the form in clinically appropriate locations to support diabetic, health maintenance and cardiovascular guidelines.

Purpose

To standardize documentation and provide clinical decision support at the point of care.

Ages

This form was created primarily for adults seen for office visits. It is used both for acute and chronic problems. The clinical decision support is geared specifically for adults. This form could be used for all other age groups but elements of it would not be particularly appropriate for younger patients.

Special Features

  • Standard SOAP format;
  • Pull forward histories;
  • Risk page with smoking cessation supports;
  • Smoking cessation support;
  • ROS with pre-sets and CDS specific to the patient;
  • PE with previous buttons;
  • Assessment with pull forward of last assessment;
  • Plan with dynamic medication list handout and instructions for patient, pull forward previous plan E/M coding cheat sheet.

Sources of Evidence for Clinical Decision Support

  • USPSTF;
  • NCQA.
Created: 04-03-2006
Last Updated: 04-03-2006

Laboratory Visit

Downloads

Screenshots

Clinical kit

Description

A form designed to enter laboratory work performed by outside laboratories which will directly populate the flow sheet.

Purpose

To facilitate entry of data which has not crossed electronically.

Ages

This form can be used for all ages although it is specifically designed for an adult age group.

Special Features

  • Form designed to facilitate pushing observation data to the preferred obs term for appropriate data capture;
  • Simplified data entry as compared to using the flow sheet.
Created: 03-01-2006
Last Updated: 06-18-2013

Medicare Preventative Services

Pain Management

Downloads

Screenshots

Clinical kit

Description

This is a form designed to be a pull in component of a standard office form to specifically address the documentation needed for chronic pain management and the development of a narcotic contract. The form records all data in discrete fields and allows for it to be pulled forward with the next use of the form by the click of a radio button. It also promotes the use of a standard problem and directive to indicate chronic pain management with the use of a radio button. Once the form is completed it can auto populate an informed consent letter and narcotic contract for the patient to sign.

Purpose

  • To standardize documentation of chronic pain management.
  • To facilitate the creation of a narcotic contract.

Age

Adult

Special Features

  • Push to clinical list of pain management diagnosis;
  • Ability to pull forward values;
  • Ability to see previous values;
  • Ability to auto populate narcotic contract.

Sources of Evidence

There are very limited resources for evidence based approaches to pain management. Most of what exists is expert opinion and guidelines promulgated by groups including the American Pain Society, DEA, State Board of Medicine etc. The form was specifically created to recognize these recommendations incorporate them within a usable form that would allow retrieval of information.

Created: 12-28-2005
Last Updated: 06-17-2013

Report Metrics

Downloads

Screenshots

Description

This form was designed to facilitate entry of patient data that was being collected to support efforts for the Heart Stroke Recognition Program, Diabetes Physician Recognition Program, as well as for routine preventative health care guidelines, (e.g. colonoscopy).

Purpose

To facilitate meeting the recommendations and requirements of the above mentioned programs.

Ages

The form is specifically designed for an adult age population.

Special Features

  • Form designed to facilitate pushing observation data to the preferred obs term for appropriate data capture;
  • Simplified data entry as compared to using the flow sheet.

Sources of Evidence for Clinical Decision Support

  • While the form itself does not have clinical decision support features the data collected is derived from the programs referenced above.

Created: 01-30-2006

These form were developed for use within our organization. We make no claims as their accuracy or clinical content; therefore, testing is suggested prior to implementation within the clinical environment. The forms or their clinical decision support is not meant to replace clinical judgement. Verification of the accuracy of the clinical content and decision support is the sole responsibility of the user.