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:
(firstName) presents to the office today for a follow up visit concerning (his_her) {right | left | bilateral} knee symptomatology.
{The patient denies any injuries subsequent to their previous visit. | The patient denies any injuries since their last visit. | The patient denies any injuries subsequent to their initial injury. | The patient notes that there was a new injury since their last visit to this office. {NEW INJURY KNEE}} {The patient notes that there has been some modest improvement in their condition since the previous visit. | | The patient notes that there has been no improvement in their condition since the previous visit. | The patient notes that there has been no change in their condition since the previous visit. | The patient notes that there has been worsening in their condition since the previous visit. | There has been a complete resolution in the symptoms since the last visit.} {Chiropractic therapy has been continued since the last visit and has been found to be helpful. | Chiropractic therapy has been continued since the last visit but, unfortunately, has not been helpful. | Chiropractic therapy has been discontinued since the last visit. | Physical therapy continues to be undertaken, and has been helpful. | Physical therapy continues to be undertaken, but unfortunately has not been helpful. | Physical therapy has been discontinued since the last visit. | There is no therapy currently being performed. | The patient has been compliant with their therapy program. | The patient has been not been compliant with their therapy program. | The patient has continued therapy with some relief.} {Celebrex is being used, without difficulty, and with good results. | The patient will be changed to Mobic 7.5 mg 1 TAB PO QD. | Celebrex is being used, without difficulty, with fair results. | Vioxx is being used, without difficulty, with fair results. | Vioxx is being used, without difficulty, with good results. | Ibuprofen has been utilized with good results. | | Anti-inflammatory medications have been discontinued because of gastro-intestinal complications. | Anti-inflammatory medications have not been utilized because of a past history of gastro-intestinal difficulties. | | Advil | Aspirin | Accupril | Accutane | Adalat CC | Allegra | Augmentin | Axid | Azmacort | BuSpar | Calan SR | Cardizem CD | Cardura | Claritin D | Clozaril | Cordarone | Coumadin | Daypro | Depakote | Dilacor XR | Dilantin | Flonase | Fosamax | Glucophage | Humulin 70-30 | Humulin NPH | Hytrin | Imdur ER | Imitrex | K-Dur | Lamisil Oral | Lanoxin | Lescol | Lipitor | Lodine | Lotensin | Mevacor | Norvasc | Ortho-Novum | Oruvail | Paxil | Pepcid | Pravachol | Premarin | Prempro | Prevacid | Prilosec | Prinivil | Procardia XL | Propulsid | Prozac | Relafen | Rezulin | Risperdal | Serevent | Serzone | Sporanox | Synthroid | Ticlid | Toprol XL | Trental | Trtiphasil | Ultram | Vasotec | Zantac | Zestril | Ziac | Zocor | Zoloft | Zovirax | Zyprexa | Zyrtec} {The patient has been working. | The patient has been working at full duty. | The patient has been working at full duty, but is having problems with the current work load and needs new restrictions imposed. | The patient is not currently employed, but anticipates starting a new job in the near future. | The patient has been working at light duty, but feel ready to begin unrestricted duty after today's evaluation. | The patient has been working, but at a restricted duty. | The patient has not been working at all.}
{No additional studies are available for today's visit. | The patient presents to the office today with an MRI of the right knee. The results show no evidence of meniscal tear or ligament injury. | The patient presents to the office today with an MRI of the left knee. The results show no evidence of meniscal tear or ligament injury. | The patient presents to the office today with an MRI of the left knee. The study reveals evidence of a tear to the posterior horn of the medial meniscus. | The patient presents to the office today with an MRI of the right knee. The study reveals evidence of a tear to the posterior horn of the medial meniscus. | The patient presents to the office today with an MRI of the left knee. The study reveals evidence of a tear to the posterior horn of the medial meniscus, tear of the medial collateral ligament, and a tear to the anterior cruciate ligament. | The patient presents to the office today with an MRI of the right knee. The study reveals evidence of a tear to the posterior horn of the medial meniscus, tear of the medial collateral ligament, and a tear to the anterior cruciate ligament. | The patient presents to the office today with an MRI of the left knee. The study reveals evidence of a tear to the anterior cruciate ligament. | The patient presents to the office today with an MRI of the right knee. The study reveals evidence of a tear to the anterior cruciate ligament. | The patient presents to the office today with an MRI of the left knee. The study reveals evidence of a tear to the posterior cruciate ligament. | The patient presents to the office today with an MRI of the right knee. The study reveals evidence of a tear to the posterior cruciate ligament.}
PHYSICAL EXAMINATION:
{The patients right knee range of motion is observed as follows:
Knee flexion - {KNEE FLEXION} degrees
Active knee extension - {KNEE ACTIVE EXTENSION} degrees | The patients left knee range of motion is observed as follows:
Knee flexion - {KNEE FLEXION} degrees
Active knee extension - {KNEE ACTIVE EXTENSION} degrees | The patient has deep flexion pain in the left knee with limited range of motion. | The patient has deep flexion pain in the right knee with limited range of motion. | The patient lacks terminal extension of the left knee. | The patient lacks terminal extension of the right knee. | The patient has full range of motion in the right knee. | The patient has full range of motion in the left knee. | The patient has full range of motion in bilateral knees.}
{The motor function in both lower extremities is within normal limits. | The motor function in both lower extremities is noted to be diminished. | The motor function in the RLE is noted to be diminished. | The motor function in the LLE is noted to be diminished. | The motor function in the LLE is noted to be severely diminished. | The motor function in the RLE is noted to be severely diminished. | The motor function in the RLE is noted to be severely diminished with obvious muscle atrophy. | The motor function in the LLE is noted to be severely diminished with obvious muscle atrophy.} { | Reflexes in both lower extremities are noted to be equal and symmetrical. | Reflexes in both lower extremities are noted to be diminished. | Reflexes in both lower extremities are noted to be severely diminished. | Reflexes in both lower extremities are noted to be absent. | Reflexes in the LLE are noted to be absent. | Reflexes in the RLE are noted to be absent. | Reflexes in the RLE are noted to be diminished. | Reflexes in the LLE are noted to be diminished. | Reflexes in the LLE are noted to be hyper-reflexive. | Reflexes in the RLE are noted to be hyper-reflexive.} {On palpation of the right knee , the patient has tenderness over the pes anserinus bursa. | On palpation of the left knee, the patient has tenderness over the pes anserinus bursa. | On palpation of the left knee, the patient has tenderness over the patellar facets. | The patient has no evidence of varus or valgus instability to the left knee. | The patient has no evidence of varus or valgus instability to the right knee. | The patient has evidence of valgus instability to the right knee. | The patient has evidence of valgus instability to the left knee. | The patient has evidence of varus instability to the left knee. | The patient has evidence of varus instability to the right knee. | The patient has evidence of laxity to the ACL in the right knee with a positive Lachman's test. | The patient has evidence of laxity to the ACL in the left knee with a positive Lachman's test. | The patient has evidence of laxity to the PCL in the left knee with a positive Sag sign. | The patient has evidence of laxity to the PCL in the right knee with a positive Sag sign. | The patient has tenderness over the posterior horn of the medial meniscus in the left knee with a positive McMurry's test. | The patient has tenderness over the posterior horn of the medial meniscus in the right knee with a positive McMurry's test. | The patient has tenderness over the patellofemoral region with a positive patellofemoral grind test and crepitation throughout motion in the left knee. | The patient has tenderness over the patellofemoral region with a positive patellofemoral grind test and crepitation throughout motion in the right knee. | The patient has no palpable tenderness to the right knee. | The patient has no palpable tenderness to the left knee. | On palpation of the right knee, the patient has tenderness over the patellar facets. | On palpation of the left knee, the patient has tenderness over MCL. | On palpation of the right knee, the patient has tenderness over MCL.} {Visual inspection and palpation of the right knee reveals no evidence of an effusion or infection. | Visual inspection and palpation of the left knee reveals no evidence of an effusion or infection. | Visual inspection and palpation of the left knee reveals evidence of a grade I effusion. | Visual inspection and palpation of the right knee reveals evidence of a grade I effusion. | Visual inspection and palpation of the right knee reveals evidence of a grade II effusion. | Visual inspection and palpation of the left knee reveals evidence of a grade II effusion. | Visual inspection and palpation of the left knee reveals evidence of a grade III effusion. | Visual inspection and palpation of the right knee reveals evidence of a grade III effusion.}
{Inspection of the right knee reveals well healed portal scars from a previous arthroscopy. | Inspection of the left knee reveals well healed portal scars from a previous arthroscopy. | Inspection of the left knee reveals a well healed mid-line scar from previous ACL reconstruction. | Inspection of the right knee reveals a well healed mid-line scar from previous ACL reconstruction. | Inspection of the right knee reveals no surgical scars. | Inspection of the left knee reveals no surgical scars. | Inspection of bilateral knees reveals no surgical scars.} The patient's gait is observed to be {antalgic on the affected side. | antalgic to the left. | antalgic to the right. | normal. | abnormal as follows:}
DIAGNOSIS:
{Right knee sprain - strain. | Left knee sprain - strain. | Right knee internal derangement. | Left knee internal derangement. | Right knee ACL tear. | Left knee ACL tear. | Right knee PCL tear. | Left knee PCL tear. | Right knee medial meniscus tear. | Left knee medial meniscus tear. | Right knee patellofemoral chondromalacia. | Left knee patellofemoral chondromalacia. | Right knee patellar subluxation. | Left knee patellar subluxation. | Right knee patellar fracture. | Left knee patellar fracture. | Right knee tibial plateau fracture. | Left knee tibial plateau fracture. | Right knee contusion. | Left knee contusion.}
PLAN:
{The patient was instructed on a home exercise program consisting of closed chain exercises and was able to demonstrate proficiency. | I have recommended to the patient that they continue with the prescribed therapy and anti-inflammatory medications as directed. | Secondary to lasting complaints, I will schedule the patient for an MRI of the left knee to evaluate for internal derangement. | Secondary to lasting complaints, I will schedule the patient for an MRI of the right knee to evaluate for internal derangement. | I have recommended that the patient undergo a series of Hyalgin injections starting today with the first of five shots into the left knee. | I have recommended that the patient undergo a series of Hyalgin injections starting today with the first of five shots into the right knee. | I have recommended that the patient undergo a series of Hyalgin injections starting today with the first of five shots into bilateral knees. | Based on physical examination and positive studies, I recommend that the patient be scheduled for out-patient right knee arthroscopy. A history and physical examination was performed and a consent was signed and dated then attached to the chart. All of t} {I would recommend that there be no limitation in the work activities at this point in time. | I would recommend that this patient be maintained at a light duty work status. | I would recommend that this patient be maintained at a moderate duty work status. | I would recommend that this patient be maintained at a sedentary work status consisting of administrative type task only. | I would recommend that this patient be maintained at a sedentary work status. | Since this patient still has right knee symtomatology, I would recommend that they continue working, but only within their pain tolerance. | Since this patient still has left knee symtomatology, I would recommend that they continue working, but only within their pain tolerance. | The patient is going to attempt a resumption of their current occupation with the understanding the an adjustment in work status may be required if the task prove to be difficult or painful.} {I have asked this patient to return to the office in 1 week. | I have asked this patient to return to the office in 2 weeks. | The patient has been asked to return with their MRI films in hand for interpretation and further recommendations. | I have asked this patient to return to the office in 3 weeks. | I have asked this patient to return to the office in 4 weeks. | I have asked this patient to return to the office in 4 weeks, at which time the patient will likely be placed a MMI. | I have asked this patient to return to the office in 6 weeks. | I have asked this patient to return to the office in 8 weeks. | On the patient's next visit they will receive their next Hyalgin injection. | The patient will receive a steroid injection into the right knee if the symptoms have not improved. | The patient will receive a steroid injection into the left knee if the symptoms have not improved.}
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