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The Comprehensive Assessment Form is a complete
record of the patient's assessment detailing the
history and review of systems, the physical exam, the
primary and secondary diagnoses and the plan for
treating each diagnosis.
Information may be entered by the provider directly,
by transcription or by using one of our medEntry
specialty-specific "phrase builder" functions.
medEntry specialty screens are self-instructional and
provide many context-sensitive help/hint links to help novice users.
This form, as with any MsdC form, can be as brief or as
complex as necessary. Even a very detailed form can
be completed within minutes with medEntry's
timesaving features.
medEntry allows the user to chart by exception i.e. only enter information that
has changed for the patient.
For example, just before this form is displayed, medEntry asks if any information should be copied
forward from previous encounters to this new form.
If the user answers affirmatively, certain
pre-defined data items are filled in automatically.
This is especially helpful when recording the
patient's individual and family history, previous
hospitalizations, etc. If
someone has already documented this information, the
user can simply with a single click copy it to the current form and
then update just the things that have changed. The original document from
which the information was taken is unchanged, and the
current document contains a complete and up-to-date
record of the patient with minimal time and effort by the provider.
  
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