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Medical Record Documentation Software | EMR & EHR | MicroMD

MicroMD Medical Record Documentation Software

Easy EHR Documentation

MicroMD EMR charting methods allow you to choose the style of medical record documentation that works for you.

With MicroMD EMR, each clinician chooses their personal preference regardless of how others in the practice choose to work:

  • Document details required for ICD-10 code specificity: Quickly assign codes
  • Text templates: Free text or handwriting recognition that is formatted into templates similar to paper charts
  • Encounter Wizards: Point-and-click “wizards” following clinical pathways
  • SOAP templates: Standard or custom templates with discrete data entry
  • Voice recognition: Speech recognition that is formatted into templates

For common conditions, templates allow physicians to quickly apply pre-defined treatment plans and more, eliminating redundant entries and providing complete medical record documentation of the visit.

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MicroMD EMR provides the physician with easy access to vital signs, lab results, allergies, medication lists and all other patient data for review during the exam. In addition, setting and monitoring patient goals, health maintenance or custom treatment plans are all available to the physician at the point of care. This historical information, together with clinical decision support rules built into the system, will present you with the information necessary to provide the highest quality of healthcare.

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Patient Overview allows providers to add customized chart views, including data grids and graphs to the patient chart. From here, providers can update and review patient medical information, assess progress towards healthcare goal, and keep the patient compliant with Health Maintenance and Immunization recommendations.

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MicroMD EMR templates allow providers to pre-set responses to speed the medical record documentation process. Responses my be defaulted to a particular response and changed as needed – or – responses may be “suggested” and added to the note as deemed necessary by the provider. In addition, checklists of probable responses can be created to allow a single template to serve as many possible assessment and plan combinations.

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Patient Monitor is a one-click summary that gives the provider a review of the patient “at a glance”. Available to providers throughout the system, the Patient Monitor is a view of the patient that is “personalized” to show providers the portions of the chart that would normally be reviewed during patient encounters. Areas of the chart that require attention are highlighted to draw provider attention to action items and allow for “single-click” navigation to the associated chart areas.

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E&M Coding for Confident Reimbursement

With MicroMD EMR, you’ll bill for all evaluation and management (E&M) services you provide—while minimizing the risk of overbilling. More than a tool for simply recording visit details, MicroMD EMR’s comprehensive E&M calculator generates accurate codes for you. This tool helps prevent undercoding and maximizes reimbursement for the services you provide.

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Meaningful Use Quality Measures Button

The quality measures button provides you with an at-a-glance alert for providers to know whether a chart or encounter meets CMS EHR Incentive Program meaningful use requirements, as well as which data fields need completion.

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