Pursuing perfection by specialty and subspecialty

Thorough documentation of EKG results and other cardiac testing, cardiac risk factor assessments, timelines of symptoms, ICD and pacemaker checks, smoking/tobacco cessation, etc.

Documentation of nutritional assessment and diet regimens, IBS history, bowel movements with automated grading for GI scoring systems (e.g. Bristol Stool Chart and Glasgow-Blatchford Bleeding Scores), etc.

Documentation of TNM staging, ADL status and ECOG status for clinical trials, comprehensive EOM/MIPS quality measures, advanced care planning discussions, etc.

Detailed documentation for urological symptoms, sexual function, past surgeries, procedures (cystoscopy, prostate biopsy, and urinary catheterization), imaging reports, and management of urologic cancers (including prostate, bladder, and kidney cancers), etc.

Documentation of patient's subjective emotional and behavioral symptoms, past or current trauma or abuse, current medication regimens with response to treatment, etc., all while supporting long (> 1 hour) visits, the ability to capture direct quotes from the patient, and supporting psychotherapy 90833 add-on CPT codes.

Documentation for pediatric growth and development milestones, pediatric nutrition and feeding history, pediatric mental health assessments, pediatric physical examinations, etc. and support for > 20 pediatric subspecialties.

Ability to interpret conversations with memory-related conditions (dementia, Alzheimer's, etc.) and thorough documentation for patients with multiple complex chronic conditions, cognitive assessments such as mental status exams, discussions with nursing home staff and family members, ICD.10 and HCC coding support, etc.

Documentation for perimenopause, menopause, and postmenopause symptoms and transitions, management of hormone replacement therapy, sexual well-being and partnership dynamics, precise menstrual cycle tracking, GTPAL scores, fertility treatments, deviations from normal baselines, etc.

Accurately document lab results and pathology results (complete blood counts, coagulation profiles, bone marrow biopsies, etc.), transfusion history details, genetic counseling, family history and risk assessments for hereditary hematologic conditions, etc.

Documentation of liver disease assessments, medication management (including antiviral therapies, immunosuppressive agents, and potential drug interactions), transplant evaluations (patient eligibility, donor compatibility, and post-transplant care), diagnostic procedures (imaging, liver biopsies, liver function tests, viral serologies), etc.

Comprehensive documentation support for complex chronic diseases (diabetes, COPD, CHF, CKD, etc.), problem-based charting, Medicare AWVs, referral letters to specialists, etc.

Documentation of electrolyte imbalances (e.g. hyperkalemia, hyponatremia, and metabolic acidosis), dialysis treatment, compliance, and complications (including hemodialysis and peritoneal dialysis), kidney transplant evaluations (donor and recipient compatibility assessments, pre-transplant workup, and post-transplant follow-up care), etc.

Documentation of comprehensive neuro exams without explicit dictation, thorough imaging and EEG/EMG interpretations, stroke symptoms, LKWT, deviations from normal baseline functions, detailed timelines for seizure events, etc.

Comprehensive documentation across prenatal and labor care, high-risk pregnancies and corresponding treatment plans, post-partum support for both mothers and newborns, etc.

Documentation of ophthalmic assessments (capturing IOP, visual acuity, refraction measurements, slit lamp exam and fundoscopic exam findings, etc.), common ophthalmic imaging tests (OCT, Fluorescein Angiography, etc.), in-office procedure documentation (Anti-VEGF injections, laser procedures like ALT and SLT), etc., all while leveraging appropriate ophthalmic laterality abbreviations (OS, OD, OU).

Comprehensive documentation for pulmonary function tests (spirometry, lung volumes, diffusion capacity), sleep study interventions, CPAP/BiPAP therapy, chronic lung disease management, smoking history and cessation education, education for using nebulizers, inhalers and other respiratory therapies, etc.

Accurate documentation of affected joints and muscle groups, impact on ADL status, detailed family history of rheumatologic diagnoses, treatment response, etc.

Documentation support for acute and chronic conditions, in-office procedures, complexity-based coding, work note requests, workers' compensation documentation, etc.

Comprehensive documentation of otolaryngologic history, sleep apnea and snoring management support including CPAP therapy, sleep study reports, previous surgical interventions, etc.

Documentation of hormone levels and endocrine function (e.g. for diabetes, thyroid diseases, metabolic disorders, osteoporosis, and adrenal dysfunctions), management of insulin therapy and hormone replacement, blood sugar trends, treatment response, individualized education plans, etc.

Precise documentation for skin cancer screenings (e.g. mole mapping and dermoscopy findings), in-office procedures (e.g. skin biopsies, excisions, injectables, laser treatments, and chemical peels), longitudinal tracking of chronic dermatologic conditions, detailed patient education, etc.

Connect with our team to learn more.