ISALUS EMR Cheat Sheet
The highlighted sections are what you will see on your desk top in the EMR section
Allergies
Patient History
Vitals
←
Medications
Problem List
Immunizations
Encounter History
These tabs allow you to
bring up a history of
previous visits. Ex: if
you open the Patient
History tab and hit
display history it will
pull up all the previous
patient histories that
have been completed.
Chart Tabs:
Summary
Vitals
Allergies
History
ROS
Exams
Order Entry
Problem List
Prescriptions
Immunizations
HPI
Treatment Plan
The Chart Tabs
allow you to enter
information for the
specific day that
you are seeing the
patient
Chart Tabs: This is where information for the patient’s visit is recorded. Info needs to be
recorded in order (vitals through treatment plan). The summary tab accumulates the info you
are entering and allows you a brief snap shot of what is happening throughout the visit. As you
enter info the tabs above and to the left will begin to fill with the info you are entering.
Below is the info that MUST be completed under each of the chart tabs. You will see that there
is a lot more information that can be recorded in each chart tab. This section of ISALUS could
not be changed to meet our specific needs so the information that is not pertinent to us can be
left BLANK. If you record the information it will end up on the SOAP Note which we do not
want! Anything with a red * must be completed. Remember to use the Superbill to record data
that needs to be inputted in multiple places.
Vitals




LMP
Height, weight and BMI (BMI autocalculates)
Blood pressure (include extremity and sit/stand)
SAVE! Every time you complete a chart tab you have to push SAVE or your
data will be erased!
Allergies




Add allergies by searching and choosing from the drop down list (no known
allergies is in the drop down list).
Cannot search using abbreviations!
Once you add the allergen you must add at least one symptom.
SAVE!
History
As you enter information into each of the tabs in this section it will auto populate the Summary
tab at the top.













Demographics: EVERYTHING must be completed in this section. Looks a lot like CVR
info.
Significant Illnesses:
Self explanatory- check
Hospitalizations:
“No” and move on or
Surgical History:
check “yes” and record
Disability History:
the necessary info
Dental Care:
Social History: Complete only the following: Abuse, Tobacco use, Caffeine use,
Recreational drug use, and ETOH use. Leave everything else BLANK.
Family Medical History: Complete everything up to cause of death (COD). COD can be
left BLANK.
Menstrual/Obstetrical History:
Complete ALL
Sexual History:
fields
Contraceptive History:
Immunization History:
SAVE!
ROS:


Complete EVERYTHING
SAVE!
Exams:



Templates: Scroll down to find the appropriate form for the visit.
Complete ALL fields on them template.
SAVE!
Order Entry:







Follow Up Visit: Enter (order) all necessary follow up visits.
Referral: Enter (order) all necessary referrals you MUST choose whoever is at
the front desk as the PROCESSOR (person who needs to perform the order)!
In House Orders: Enter (order) all in house labs (UA, UPT, hemoglobin, etc)
AND Gardasil and Rocephin injections (if being given during THIS visit). You
have to assign a specific PROCESSOR.
Labs: Enter (order) all labs that are processed outside of the clinic (pap,
GC/CT, etc.). You have to assign a specific PROCESSOR.
Breast Imaging: Enter (order) the procedure and assign a PROCESSOR.
Other Orders: Enter (order) anything not listed above and assign a
PROCESSOR (ex: Needs to have an ROI signed so we can get Pap results).
SAVE!
Problem List:




Record patient problems by CPT Code by performing a search in the scroll down list.
Left click over the problem to edit it (add notes, remove the problem, etc.)
Alerts will appear next to the problem when applicable.
SAVE!
Prescriptions:




Perform a drug search to find the medication (top left of the page).
The following info has to be completed on the script WHEN WE ARE THE ORDERING
CLINICIAN:
o Drug (name and strength)
o Dispensing qty and method (pack, tablet, ring, etc.)
o Route and frequency
o VOID Date (need to record void date as 13 months from original script date).
o Patient Reported field should say “NO” (change by left clicking).
The following needs to be completed to record medications that the patient is currently
on from OTHER CLINICIANS:
o Drug (name and strength if known)
o Dispensing route and frequency (if known)
o Patient Reported field should say “YES” (change by left clicking).
SAVE!
Immunizations:

Use for Gardasil injections only
HPI:



More CVR date.
Complete ALL
SAVE!
Treatment Plans:





More CVR data
Abnormal Lab Follow Up: Document all abnormal lab follow up.
General Counseling and Education: Document counseling and education provided.
Treatment Provided: Document what patient was treated for (only includes certain
diagnosis).
SAVE!
Notes:
* To record Lab results (in house or outside labs) you go into the EXAM Chart Tab and pull
down the appropriate template:
 “Internal Lab Results”- to record in house results
 “External Lab Results”- to record PAP and GC/CT and any other labs sent out for
processing.
 SAVE! After each enrty!