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The Basic EMR component provides comprehensive electronic medical record functionality for storing, managing, and accessing patient health information in a secure, organized manner.

For Providers

Document clinical encounters, manage patient records, and access complete medical histories during consultations.

For Admins

Oversee record management, ensure compliance, and manage documentation templates across the practice.

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Core Features

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Patient Records

  • Demographics: Personal and contact information integrated from Patient Profile
  • Medical History: Past conditions, surgeries, hospitalizations, and family history
  • Medications: Current and past prescriptions with dosage and frequency tracking
  • Allergies: Drug, food, and environmental allergies with severity indicators
Patient medical record overview showing demographics and medical history

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Clinical Documentation

  • SOAP Notes: Structured documentation (Subjective, Objective, Assessment, Plan)
  • Visit Notes: Encounter documentation with customizable templates
  • Orders Management: Lab orders, imaging requests, and referrals
  • Billing and Coding: ICD-10 and CPT code integration for charge capture
  • Vitals Recording: Blood pressure, temperature, weight, and other vital signs
Clinical encounter documentation showing SOAP notes and orders

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User Workflow

1

Login

Provider logs in and accesses dashboard
2

Navigate to EMR

Navigate to EMR patient record from patients table on dashboard
3

Review Medical History

Check previous encounters, medications, allergies, and conditions
4

Optional: meet with Patient

Join call with patient and open EMR within video call
5

Document Current Visit

Create SOAP note using templates or free text documentation
6

Update Clinical Data

Add diagnoses, update medications, record vitals, and create orders
7

Finalize Encounter

Complete billing codes and order approvals

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Usual Component Interactions

The Basic EMR serves as the central repository for all patient health information: Core Integration:
  • Patient Profile: Pulls demographic information and contact details
  • Appointment Bookings: Links encounters to scheduled appointments
  • Intake Forms: Populates initial medical history from patient-submitted forms
Common Enhancements:
  • Labs Component: Automatic integration of laboratory results into patient records
  • Telehealth: Documentation of virtual visits with video encounter notes
  • Billing Component: Charge capture from documented procedures and diagnoses
  • Secure Messaging: Patient-provider communication linked to medical record
  • Notifications: Alerts for critical results and documentation requirements

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Implementation Examples

The Basic EMR can be customized for different practice needs:
Situation: You need to set up SOAP note templates for common visit types,
"Let's configure SOAP note templates for common visit types. 
Leave the template empty for now, we will give details later.
These templates should display as placeholder text when provider opens a patient's EMR. 
Add tabs for vitals and labs integrations."