The Eloquent Physician® is an Electronic Charting program which can be utilized to produce physician’s charts with amazing speed in many clinical settings.
An EMR (Electronic Medical Record) program is utilized to produce medical records in a physician's office, clinic or hospital based setting. Some EMR software programs contain advanced features such as electronic data exchange (EDI) between the EMR and a laboratory, radiology facility and/or pharmacy.
The Eloquent Physician does not contain these more advanced features. However, if your main interest is in producing ‘Eloquent’ medical records rapidly, you owe it to yourself to review the features of this program.
If you are looking for an EHR (Electronic Health Record) which can be accessed by patients over the Internet, for example, or a full featured EMR, please visit EMRConsultant.com. At EMRConsultant.com you may enter the parameters that are most important to your medical group, and these will be compared with a database of EMR and EHR programs. EMR Consultant will then provide you with a list of Electronic Medical Records programs which it believes may suit your particular practice setting.
In the meantime, please review the following sample medical chart note. It is an example of the capabilities of The Eloquent Physician. To learn more, please call 1.800.245.2133. |
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HISTORY:
Since (firstName)'s most recent visit (he_she) states that (he_she) as had complete resolution of (his_her) symptoms. (He_She) relates that (his_her) treatment consisting of { | antibiotics | anti inflammatory medications | home remedies | medications | physical therapy | surgery | dietary restrictions} has been effective in alleviating the pain and discomfort associated with (his_her) low back injury. Treatment has consisted of { | antibiotics | anti inflammatory medications | home remedies | medications | physical therapy | surgery | dietary restrictions}.
There have been no further studies performed since the last visit. The patient has been receiving physical therapy for treatment of (his_her) low back injury, which (he_she) states has been helpful in alleviating (his_her) symptoms.
PHYSICAL EXAMINATION:
Range of motion of the lumbosacral region is measured and the following ranges are noted: [Please note, the value under "AMA ROM" is the value given as normal in the American Medical Association Guides to the Evaluation of Permanent Impairment, Fourth Edition.]
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|LUMBOSACRAL |PT'S ROM / AMA ROM|
|Flexion |{0 | 5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100}° / 60° |
|Extension |{0 | 5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50}° / 25° |
|Left Lateral Bending |{0 | 5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50}° / 25° |
|Right Lateral Bending|{0 | 5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50}° / 25° |£
The lower limb motor strength is manually tested and is rated on a scale of 0 to 5, with 5 being active movement against gravity with full resistance, [as per the American Medical Association Guides to the Evaluation of Permanent Impairment, Fourth Edition, page 151.] The following findings were noted:
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|MOTOR STRENGTH |RIGHT |LEFT |
|Extensor Hallucis Longus|{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|
|Anterior Tibialis |{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|
|Peroneals |{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|
|Quadriceps |{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|
|Hamstrings |{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|
|Hip Flexors |{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|{0 | 1+ | 2+ | 3+ | 4+ | 5+} / 5|£
The lower limb deep tendon reflexes are tested and are noted to be as follows: [2+ is average, and the values should be bilaterally symmetrical].
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|REFLEXES |RIGHT |LEFT |
|QUADRICEPS|{0 | 1 | 2 | 3 | Trace} / 2 |{0 | 1 | 2 | 3} / 2 |
|ACHILLES |{0 | 1 | 2 | 3 | Trace} / 2 |{0 | 1 | 2 | 3 | Trace} / 2 |
|BABINSKI'S|{downgoing | upgoing}|{downgoing | upgoing}|£
Straight leg raising is tested in the supine and sitting positions, by flexing the hip passively, and the following findings are noted: Please note that 70° or more with no pain in the leg is negative test. The Lasegue's test is performed by dorsiflexing the foot and ankle at the point of maximum hip flexion. If pain radiates into the leg, past the knee, this is considered a positive Lasegue's sign.
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|SLR TESTING|RIGHT |LEFT |
|Supine |{0 | 5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100}° |{0 | 5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100}° |
|Sitting |{0 | 5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100}° |{0 | 5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100}° |
|Lasegue's |{negative | positive}|{negative | positive}|£
The patient's perception of light touch and pinprick is tested in both lower extremities and is found to be {reduced | normal | increased}.
The vascular status in both lower extremities is {within normal limits | | normal | abnormal}.
(firstName)'s gait is {within normal limits | | normal | abnormal}.
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|Exam Type |Positive or Negative |Degree or Size |Location |Comments |
|Spasm |{negative | positive}|{absent | mild | moderate | severe | exceptionally severe} |{paralumbar | flank}|{The lumbar spasm is knot-like in characteristic.}|
|Tenderness|{negative | positive}|{absent | mild | moderate | severe | exceptionally severe} |{midline | paralumbar | flank}|{The tenderness is noted with deep palpation. | | The tenderness is noted with light palpation.}|
|Erythema |{negative | positive}|{clean | partially contaminated | deeply contaminated | second degree | third degree}|{midline | paralumbar | flank}|{The erythema detected in the lumbar region is localized and bright red in nature.}|
|Scars |{negative | positive}|{mild | moderate | severe | none}|{midline | paralumbar | flank}|{The scar observed in the lumbar region is well healed and is related to previous surgery.}|
|Masses |{negative | positive}|{annular | papular | vesicular | macular | fluctuant | draining}|{midline | paralumbar | flank}|{The mass detected in the lumbar region is annular in nature and non-fluctuant. The mass is non-tender to palpation and it is mobile.}|
|Abrasions |{negative | positive}|{2cm | 3cm | 4cm | 5cm | 6cm | 7cm | 8cm | 9cm | 10cm | 15cm | 20cm}|{midline | paralumbar | flank}|{ | The abrasions observed in the lumbar region appear to be minor with no sign of infection and no deep tissue involvement.}|£
ASSESSMENT:
Status post lumbosacral injury, {degenerative disk disease | herniated nucleus pulposus | lumbosacral sprain | muscle spasm} which has resolved. { | Work status - sedentary | Work status - light duty | Work status - moderate duty | Work status - heavy duty | Work status -full duty}
MMI:
In my opinion this patient has reached Maximum Medical Improvement from (his_her) injuries sustained on (dateOfInjury). Furthermore, it is my opinion that (he_she) has sustained a permanent physical impairment as it relates to those injuries. Using the {AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition | California Guides | Florida Worker's Compensation Guides | Minnesota Guides | AAOS Guides} it is my opinion that there is in total a {5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100}5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100 permanent physical impairment to the whole person which has been caused by the injuries in question. This is based upon (his_her) history, physical examination, diagnostic studies, and is consistent with (his_her) diagnosis.
PLAN:
Additional treatment or medication is not recommended at this time, however the patient was instructed that (he_she) may return to the office on a prn basis.
{A home exercise program was recommended to this patient, and complete instructions were offered prior to leaving the office.}
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