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) returns to the office today for follow up evaluation regarding (his_her) low back pain. (He_She) states that (his_her) symptoms while somewhat improved, have not yet completely resolved. (He_She) has not received any specific treatment since (his_her) last visit. {Physical therapy modalities that included ultrasound, electrical stimulation, heat, ice, massage, phonophoresis, iontophoresis, traction, joint manipulation, isometric and isotonic exercises.}
(His_Her) specific symptoms which are discussed on today's visit include {pain | swelling | weakness | numbness}.
CURRENT MEDICATIONS:
Currently (he_she) is not taking any medications related to (his_her) low back condition.
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 | 60° / 60° |
|EXTENSION | 25° / 25° |
|LEFT LATERAL BENDING | 25° / 25° |
|RIGHT LATERAL BENDING| 25° / 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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| |RIGHT|LEFT |
|EXTENSOR HALLUCIS LONGUS|5 / 5|5 / 5|
|ANTERIOR TIBIALIS |5 / 5|5 / 5|
|PERONEALS |5 / 5|5 / 5|
|QUADRICEPS |5 / 5|5 / 5|
|HAMSTRINGS |5 / 5|5 / 5|
|HIP FLEXORS |5 / 5|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|2 / 2 |2 / 2 |
|ACHILLES |2 / 2 |2 / 2 |
|BABINSKI’S|Downgoing|Downgoing|£
Straight leg raising is tested in the supine and sitting positions, and the following findings are noted: [70° or more with no pain in the leg is negative test].
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|SLR |RIGHT |LEFT |
|SUPINE |70° |70° |
|SITTING |70° |70° |
|LASEGUE’S|Negative|Negative|£
The patient's perception of light touch is tested in both lower limbs and is found to be within normal limits. There are no dermatomal abnormalities noted. There are no surgical scars noted in the lumbosacral region.
There is no tenderness to either light touch or deep palpation noted in the lumbosacral region. Similarly, there is no erythema noted in the low back region. No appreciable spasm is noted in the paraspinal musculature.
The patient's gait is satisfactory. Heel and toe walking are performed without difficulty. No list is present. The patient does not wear a lumbar brace at this time and does not require any ambulatory assistance. Vascular status is intact in both lower limbs.
ADDITIONAL STUDIES:
There are no additional studies available for review on today's visit.
ASSESSMENT:
S/P lumbosacral injury, {degenerative disk disease | herniated nucleus pulposus | lumbosacral sprain | muscle spasm} which has since improved significantly but has not yet completely resolved. {Work status - sedentary | Work status - light duty | Work status - moderate duty | Work status - heavy duty | Work status -full duty}
PLAN:
No specific additional formal treatment or therapy is recommended. However, should (he_she) wish to return to the office at any time for further evaluation (he_she) is instructed to merely call for another appointment. Pending any such worsening, (he_she) is being discharged from my care.
{A home exercise program was recommended to this patient, and complete instructions were offered prior to leaving the office.}
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