Welcome to MDoffice
Quick video guide
This short video will give you a quick overview of the MDoffice form for Medical History, Medications and Allergies. This is not a comprehensive how-to guide or a user’s manual, but rather couple of minutes of snapshots to help you understand these three sections.
While a nurse or technician checks your patient’s meds, you can also add or review both drug and non-drug allergies. If you add a new allergy, note that a patient’s current meds are shown in the drug allergy dropdown. You can use a timeline to describe the occurrence of allergic reactions.
When your patient visits, a nurse or technician can review and update his or her medical history. Forms that you can alter to fit your preferences record all past illnesses, surgeries, injuries, treatments and pertinent family and social history. Color codes indicate severity of an illness, and you can add free text if you wish.
You can easily view and update a patient’s list of past and current medications. With just a click of the mouse you can modify, continue, discontinue or refill prescriptions. Current meds for established patients will be listed.
Patient Walk Through
Perhaps the best way to see how MDoffice actually works is to follow a patient from registration, check-in, recording the encounter, through check-out and billing.
Booking appointments
Your new patient is usually registered by phone using a simple Quick Registration form. All that's typically needed is your new patient's name, address, phone numbers and gender. If your patient knows detailed information, such as insurance data, that too can be quickly entered.
To see what appointment slots are available for which doctors, front desk staff visually pick an open slot, or quickly search for one. If anybody in the practice needs to know who is seeing whom and what slots are open, this is where they'll look.
Front desk reception
Your patient's first interaction in the clinic is signing in at the front desk. His or her appointment is marked as "arrived". A printed "Superbill" can be printed that also is used as a disposable "Routing Slip" that follows your patient through the clinic.
The front desk can print a full Registration form for the patient to review and complete -- adding a digital photo if necessary so physicians and staff can recognize the patient.
The next step is to click on the 'Ready' button to initial the tracking of the patient during their entire visit in the clinic.
Capturing workup information
The staff then routes the patient to an exam room. A nurse or technician asks the questions necessary to enter the patients medical history and then their complaints in the patients chart.
Medical Hx
The nurse or technician will enter your patient's past medical history in a manner tailored to fit your office's needs. Fully customizable forms are used to record all past illnesses, surgeries, injuries, treatments and pertinent family and social history.
Medications
The nurse can now enter and review historical and current medications. If this is an established patient, their current meds will be listed. On this visit a record of all meds prescribed, continued and discontinued will automatically update the patient's med list so it's always current and ready for review.
Allergies
At the same time as the nurse is reviewing meds, drug and non-drug related allergies can also be added and/or reviewed.
CC and HPI
Next is the reason for visit, chief complaints and history of current illness. The History of Present Illness entry is divided into Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, and Associated Symptoms. These document all of the required E/M bullets.
ROS
Individual Review of Systems is next, allowing your patient to report or deny pertinent symptoms. E/M coding requirements can be documented quickly with a "Denies All," allowing the nurse to enter positive symptoms that are pertinent.
Vitals
The nurse or technician will next record height, weight, blood pressure, pulse and other vital signs or data as defined by your office.
Documenting an encounter
After the basic entries have been completed by the nurse/technician, you can review or modify any information in the chart. All it takes is a few keystrokes. As you ask additional questions, you can key in additional data or use voice or handwriting recognition.
Past encounters
You can review the information entered for this encounter or review previous encounters. This is especially useful when seeing patients with a recurring problem.
Examination
A fully customized workflow with a complement of examination forms is available for in-depth recording of observations and findings. These include any drawings that help in documenting the encounter. This process can "roll forward" all of the pertinent history from the patient's last encounter.
Lab results
If you need to review past lab results for follow-up visits, you can use the built-in flow sheets that can be put into graphs to analyze trends.
Procedures
You can order specific procedures or diagnostic tests electronically, either locally or in a hospital or facility anywhere.
Ordering medications
You can call up an electronic Rx form that you can print at the clinic or faxed or beamed electronically to participating pharmacies. A list of "favorite" medications is available to let you quickly select the most commonly used combinations of drugs and dosage. As you prescribe medications, MDoffice records the details in your patient's chart.
Assessments
The encounter is nearly complete with patient assessments. As you document the encounter, MDoffice automatically collects diagnoses. By clicking on the quick diagnosis lists, you can easily check the assessments and add different diagnostic codes. You can now note the prognosis of your patient and add information for follow-up visits.
Procedures
You can order specific procedures or diagnostic tests electronically, either locally or in a hospital or facility anywhere.
Ordering medications
You can call up an electronic Rx form that you can print at the clinic or faxed or beamed electronically to participating pharmacies. A list of "favorite" medications is available to let you quickly select the most commonly used combinations of drugs and dosage. As you prescribe medications, MDoffice records the details in your patient's chart.
Plans
Follow-up appointments, lab orders, patient education handouts, excuses, referrals, instructions, et cetera, can be easily created and noted in the patient's chart. You can mark these appropriately as you review them with your patient.
Checking out
Since the receptionist recorded your patient's coverage, co-pays and other insurance details at registration, checking him or her out is uncomplicated.
Patient check-out
Once the doctor has completed the encounter, your patient typically goes to the front desk. Any prescriptions, handouts, instructions that you've created will be waiting. The patient can also be handed a visit summary.
Follow-up appointments
To find a follow-up appointment for your patient, your receptionist opens the Appointment drawer and checks for available time slots.
Billing
The insurance plan, the amount and type of co-pay were entered when your patient was registered. Since MDoffice posted the charges and co-pay automatically, billing personnel can review the patient's charges for the day and be assured of collecting the right co-pay and assures the highest reimbursement. This feature eliminates posting steps and prevents errors to inaccurate posting.
