 | Psychiatry Medical History.
Every chart within the EMR system comprises of three forms; one for patient demographic/insurance data called General form, one for medical history called History form, and one for visits called Encounter form. There is always one copy of General and History forms associated with a chart whereas the Encounter forms can be unlimited, each corresponding to a patient's visit. Now on top of this intuitive design, the History and Encounter forms are totally user-customizable. This screenshot shows a History form customized by a psychiatrist.
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 | Psychiatry EMR's Encounter Form.
From a physician’s perspective, the encounter form is the most important part of an electronic medical records system. It is no different in case of a psychiatry practice; the encounter form is the place where a psychiatrist would be spending most of his/her time and therefore its design must facilitate fast and effective documentation. Our EMR allows for all encounter related information to be displayed in a structured manner on one single longitudinal form, a feature rarely seen even in the high-end electronic medical record systems.
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 | Psychiatry Visit Types.
The selection of visit type is usually the first step in documenting a patient encounter. The default visit types list in UniCharts contains more than 30 items to cover the needs of various specialties. However, the user can easily remove all unrelated items by visiting customization area to keep the list short and relevant to psychiatry. Almost every list and menu in the EMR software is user-customizable.
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 | Psychiatry Physical Examination.
The Physical examination section is fully customizable for psychiatry use. This is an example of our default "Physical Examination" block customized by a psychiatrist according to his/her style and needs. Even though the "Physical Examination" block in UniCharts defaults to general multi-system examination, the user may remove all default sub-sections and add number of their own subsections. This user preferred to have just one subsection and named it "Mental Status Examination".
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 | Psychiatry Encounter/Consult Notes
The encounter/consult notes are automatically generated and formatted according to the data that may have been entered on the encounter form by the physician. For example, the physical examination shown in the previous screenshot would be formatted something like this. Note that because there was only one subsection "Mental Status Examination" defined by the user in physical examination block, it has automatically become the top-level heading for that part of the note.
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 | Psychiatry ROS and HPI.
The Review of systems (ROS), History of Present Illness (HPI), or any other default block for that matter can be customized easily by the user. They can not only alter the contents of these system-defined blocks but also change their order within the encounter form as needed. This screenshot shows how a psychiatrist may transform the default ROS block to conform to the specialty.
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 | Psychiatry Specialized Documentation.
The customization of History and Encounter forms is not limited to just editing of default system blocks. If needed, a physician may add any number of new blocks to cover specialized procedures or document other facts such as patient statements or consents. And while adding new blocks, he/she has the option to select from nine different types of blocks - from checkboxes to dropdown menus to free-text areas.
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 | Psychiatry Orders and Medications.
UniCharts electronic medical records software allows for all orders, medications and codes relevant to the psychiatry specialty to be assembled in favorite lists. Once these lists are assembled, they are available on the concerned blocks and can be accessed by the psychiatrist with a single click of mouse. The entries are displayed in alphabetical order for a quick point-and-click insertion on the encounter form.
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 | Psychiatry Diagnosis and Assessment.
As with other specialties, the diagnosis and assessment in psychiatry generally translates to selection of applicable ICD codes. The unique design of our Diagnosis/Assessment block facilitates this workflow brilliantly. The block has two sections namely "Ongoing problems" and "New Problems". The helper window for ongoing problems presents that patient's master problem list whereas the helper window for new problems opens the list of physician's favorite ICD codes.
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 | Diagnosis and Assessment Format.
Any ICD codes selected as part of the diagnosis and assessment are included on the generated notes in standard sequential format, as shown in this screenshot. However, some psychiatrists prefer to have their assessment part shown in multi-axial format. This is easily achieved by adding the Axis number before respective ICD codes when doing the ICD favorite list, as described below.
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 If you prefer to have the assessment part shown in multi-axial format on generated encounter or consult notes, you just need to add the Axis number before its ICD description when building the ICD favorite list, as shown in this screenshot. The prefixes would take the form of [Axis I], [Axis II], [Axis III] respectively. There would be no prefixes [Axis IV] and [Axis V] as these will go into separate blocks on the encounter form.
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 As observations for Axis IV and Axis V do not correspond to ICD codes, they are not to be added to the ICD favorite list. Instead, they will go into separate user-defined blocks on the encounter form. While adding new blocks, you may choose from nine different types of blocks available in the EMR system. As an example, this screenshot shows a "Block With Single Dropdown" as Axis IV and a "Block With Multiple Freetext Fields" as Axis V.
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 Once the ICD codes for Axis I, II and III are added to the ICD favorite list and two new blocks for Axis IV and V are added on the encounter form template in the customization area, these instruments would become available on the actual encounter form as shown in this screenshot. All the physician has to do now is complete documentation using these instruments and the system will automatically do the formatting on resulting notes.
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 The system would automatically detect any Axis... prefixes on the encounter form and, if found, would format the Assessment/Diagnosis part of the resulting encounter/consult note in multi-axial format. If one or more ICD codes are detected without the Axis prefixes, they would still get included. All such codes would be grouped together neatly at the bottom of the Assessment/Diagnosis section on the generated note.
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