What is SmartEMR?
Smart EMR is a web-based solution, making it possible for multiple users to access patient’s records from any location using a tablet during a bedside encounter, personal laptop / desktop or smart phone. The EMR data is recorded using few clicks and encoded using international standards including ICD-10 and CPT codifications, making it ideal for data mining and research.
The EMR is able to assist the user by providing certain highlights thus avoiding multiple medical errors and improving clinical practice. The software is smart enough to solve fully programmed medical cases (Extra Features) to the extent of providing assessments and management plans based on international guidelines.
Generation of electronic prescriptions is possible thus significantly decreasing paper work and consultation times.
The software can also trigger contraindications when medical suggestions are given. It is also possible to print and edit any medical summary or prescription or even recommended tests for the patient using the E-print option in this software.
The Smart EMR is composed of the Basic Module that holds the following features
SmartEMR is equipped with a data mining module that allows the inspection of large pre-existing databases in order to create new information, this will allow the easy access and extraction of stored data in a structured manner thus permitting the possibility of statistical analysis and clarified research.
- Sex filter, which filters/hides data relevant to a specific sex from display in the opposite sex. Ex: male genital organs, female genital organs.
- Age filter, some data only pertinent to a specific age group will refrain from displaying in other age groups. Ex: pediatric physical exam, neonatal scoring systems.
It enables the software to register drugs and detect any duplications, allergies, indications, and side effects. It can also provide medical conditions in the form of a list.
Integrated into the EMR, laboratory values’ progression can be monitored using a comparative table or graphics. The data shown is fully encoded making it available for statistical analysis or interpretation by the EMR or medical cases.
This software has special abilities to access and interpret data available from previous entries and formulate precautions and highlights whenever applicable, thus helping the user to avoid some medical errors and dramatically improves the way of practice.
NB: even if the user is unaware of the nature of a new drug being taken by the patient, the software has the ability to recognize the drug’s property and provide highlights whenever necessary.
It enables the user to print documents or any medical record, prescription or even laboratory prescriptions anywhere using the E-print or cloud option. In addition to editing any printing summary before the action.
SmartEMR has a unique ability to access, analyze and interpret the data present in history of present illness; thus highlighting to the user if any of the active drugs being taken by the patient may aggravate the current condition or complaint of the patient. A highlight will be provided automatically labeling the specific drug and the symptoms that may be affected. This is possible by adding to the EMR a comprehensive database of coded chief complaints.
History of Present Illness
can be written using free text typing or loading a previously saved text template that can be modified at will. There are 25 preset templates created based on North American Standards where the software provides by itself a list of radio buttons and checkboxes relevant to a certain chief complaint to be filled by the user.
Past Medical History
Past Medical History is stockpiled using ICD-10 codifications if the patient has a substantial past medical history, the user will be able to fill the data adequately after a certain significant time and acquaintance with the ICD-10. In order to solve this issue, a unique feature is created where the user can click preset checkboxes and the software will fabricate the corresponding codes in a small period of time.
Past Surgical History
Past Surgical History will be set using CPT (current procedural terminology) CPT codes.
Social History will be furnished including marital status, children, occupation, tobacco intake, alcohol intake, caffeine intake, physical activity, and use of illicit drugs.
Review of Systems
A full review of systems is built on North American Standards
It is provided including the sexual orientation, sexual activity (frequency, number of partners, use of protection or contraceptives etc…) and a complete history of previous sexually transmitted diseases.
Family History is encoded according to the ICD-10 database. This makes it possible for the software to interpret the data present into the family history making it useful for risk assessments and in medical cases.
A comprehensive history is available including the age of menarche, pregnancy status, previous pregnancies (including any abortions, complications, mode of delivery, etc.) and detailed menstrual period history.
Past Psychiatric History
Past Psychiatric History is encoded according to ICD-10 database and can be displayed by free text typing and template loading.
A comprehensive list is available in an encoded format making it possible for the software to provide highlights and warnings. Allergies are classified according to drug, substance, food, pollen, dust, animal, contact, insect, etc. in case of drug allergy, the user can either provide the trade name, generic name or drug type and the software will be able to provide a highlight in case of a user accidentally prescribes a similar drug or even another drug-related to the same family of the allergy-causing drug.
A full standardized category subdivided into medical systems allowing the user to set positive and negative findings by clicking a series of radio buttons and checkboxes. It is also possible for the software to interpret the positive findings thus guiding the user in his diagnosis, assessment, and planning. A physical examination can be displayed by free texting, importing templates, and attaching files or pictures.
Reports are available for history taking, physical examination, assessment and plans management, operative reports, pathology reports or any other investigational test. They can be displayed typed as free texts or editable text templates.
Scanned Reports are available in all categories of the EMR where the user is able to attach and save any relevant documents done as outpatient or available in hard copy. The basic EMR has the possibility to include all hard copy contents present in text format of the currently present medical records.