EndoVault Brochure Procedure - HBL Distributors : Products

EndoVault Gastroenterology
GI Specific Procedure Documentation
Designed specifically for the GI environment, EndoSoft GI is a Meaningful
Use Certified (ONC-ATCB EHR Modular) procedure documentation
application. With EndoSoft GI, healthcare providers quickly and accurately
document each visit of a patient from consent to discharge.
Procedure Report
EndoSoft GI was designed with departmental workflow in mind and
offers fully customizable reports, image and HD video capture as well as
database management. EndoSoft GI includes modules for Colonoscopy,
Sigmoidoscopy, Gastroscopy, ERCP, EUS, Liver Biopsy, Paracentesis and
Enteroscopy and Capsule Endoscopy.
P Meaningful Use Certified (ONC-ATCB EHR Modular)
P Enhance Quality of Care
Colonoscopy
EndoSoft Surgery Center
135 Broadway
Schenectady, NY 12144
Patient Name:
Date of Birth:
Record Number:
Date / Time of Procedure:
Referring Physician:
Endoscopist:
John Smith
09/15/1950
0159834
5/7/2012, 07:56:49
Frank Black, MD
Debbie Doe, MD
PROCEDURE PERFORMED: Colonoscopy - complete to terminal ileum.
INDICATIONS FOR EXAMINATION: Blood in stool.
INSTRUMENTS:
MEDICATIONS:
VISUALIZATION:
EXTENT OF EXAM:
LIMITATIONS:
CF 180 254875
Versed 3mg IVP, Fentanyl 100 mg IV
Good
TOLERANCE: Good
Terminal ileum
None
COMPLICATIONS: None
PROCEDURE TECHNIQUE: A physical exam was performed. Informed consent was obtained from
the patient after explaining all of the risks (perforation, bleeding, infection and adverse effects to the
medication), benefits and alternatives to the procedure which the patient appeared to understand
and so stated. The patient was connected to the monitoring devices and placed in the left lateral
position. Continuous oxygen was provided with a nasal cannula and IV medicine administered
through an indwelling cannula. After adequate conscious sedation was achieved, a digital exam was
performed and the colonoscope introduced into the rectum and advanced under direct visualization
to the terminal ileum.
The terminal ileum was identified by visual landmarks. The scope was subsequently removed slowly
while carefully examining the color, texture, anatomy and integrity of the mucosa on the way out. In
the rectum, the scope was retroflexed to evaluate for internal hemorrhoids and anorectal pathology.
The patient was subsequently transferred to the recovery area in satisfactory condition.
FINDINGS:
Normal to the terminal ileum
Internal hemorrhoids
ENDOSCOPIC DIAGNOSIS:
Normal colon
Internal hemorrhoids without complication
P Save Time & Resources
RECOMMENDATIONS:
Follow-up procedure in 10 years
Continue current medications
High fiber diet
Await biopsy results
P Increase Efficiency
CPT Code:
45384 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other
lesion(s) by hot biopsy forceps or bipolar cautery.
P Realize Revenue Growth
ICD Code:
578.1 Blood in stool
P Integrate Directly with EHR & HIS
455.0 Internal hemorrhoids without complication
Signature: _________________________________________________ Debbie Doe, MD
P World Class Training & Support
This procedure was electronically signed off on: 5/7/2012, 07:56:49 AM By Debbie Doe, MD
For the Latest Updates and Sales Information, Please Visit:
www.EndoSoft.com
[email protected]
PHOTOREPORT® by EndoSoft®
Scalable and Flexible
EndoSoft products are used by over 15,000 clinicians every day all
around the world. From individual offices to large, multi-site surgery
centers and hospitals, EndoSoft GI ensures seamless dataflow for
quick and easy access to all patient data across all enterprises.
CONSENT FORMS
- Fully customizable templates
- Multilingual
- e-Signature
Individualized Reporting
With EndoSoft GI, physicians utilize their own templates and
reporting style to document patient care. An optional speech
recognition tool offers the same comprehensive reporting hands
free.
Expert Data Reporting Tools
Over 100 standard reports and custom reporting tools, instantly
turns patient data into expert reports. Reports can be generated
to help meet regulatory requirements, prepare for audit inspections,
analyze productivity and more.
As a certified GIQUiC vendor, EndoSoft enables clinicians to
efficiently capture, track and submit GI Quality Indicators, relevant
PQRS measures and GIQuIC registry data.
P Fully Customizable by Each Physician
P Based on CMS, AGA, ACG & ASGE Guidelines
P Integrated ICD & CPT® Codes
P Canned Reports for PQRS & Pay-for-Performance
P Inventory Management & Tracking
P GIQuIC Certified with Quality Indicators
& Statistical Data Reporting
P Cancer Registry Forms
P Seamless Interface with HIS & PACS
P Optional Speech Recognition Tool
P Developed in line with HIPAA &
The Joint Commission Rules & Regulations
PRE-ENDOSCOPY EVALUATION
- Allergies
- Indications for exam
- Anesthesia classification
- Sedation goal
- History & medications
- Anticoagulants
- Physical exam
ENDOSCOPY IMAGES
- Capture & view full size images
& HD video clips
- Compare & annotate images
- Digital image archiving
- Import & export images
- Save as DICOM
PROCEDURE REPORT
- Customizable templates
- Automated CPT® & ICD codes
- Images printed directly on the report
PATHOLOGY REQUISITION
- Print labels & barcodes
- Tissue submittal details
- Pre & post operative diagnosis
- Electronic signature sign off on results
- Set recalls based on results
LETTER TO REFERRING PHYSICIAN
- Print & mail, e-mail (.pdf) or fax including images
DISCHARGE INSTRUCTIONS
- Detailed instructions with optional images
- Patient education
- Written instructions & appointment reminders
- Community agency referrals
- Multilingual
P DICOM & HL7 Compliant
www.EndoSoft.com