Medical Records

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This screen displays the medical records for the current patient - or if there is no current patient, a Select button allowing you to select a patient.

Note that this screen is for viewing and editing the patient's medical records. However, if you are in the middle of a consult, you should not be using this - you should be using the Visit Editor which is accessed via the Consult button on the Workflow|Scheduling and Workflow|Work List screens.

There are seven different screen shots below, one for each of the tabs: Summary, Problems, Reminders/Alerts, Documents, Charges, Prescriptions, and Communication.

All of these have a Select button at the top to allow you to select another patient.

All of them function as select screens. Date selection is always available, and in some you can select using the status or type.

All of them display the details of the item you have selected in the bottom part of the screen.

Summary

This shows the summary of the records. It should be obvious that the screen shot below is not taken from real practice data.

If you have set the Show Clinician preference, then the display will be as follows. Note that here the practice is using 'short names' for their clinicians (see Concepts|Users) so the display shows 'SM' rather than 'Dr Sam Michaels'.

Apart for the date, the selection fields are:
Type - this can be set to All or one of Addendum, Note, Problem, Weight, Medication, Investigation, Attachment, Form, Image, or Letter
Include Charges - uncheck this box if you don't want to show the invoice line items. You would do this if you are setting up a medical record to send off as part of a referral and you don't want your charges to be shown. This option can also be set in Preferences.
- this button changes the sort order of items within the visit - as shown it indicates that the visit items are shown in descending order, ie newest at the top. If you press the button it will change to an up arrow head indicating that the items are in ascending order with the newest at the bottom. Note that the visits themselves are always shown in descending order.
This option can also be set in Preferences.

The items in the display are partially colour coded. As you can see above, the selected item (the checkup visit) is in blue, and the other items are coloured as shown below.

As you can see problems are pink/red, medication light brown and weight a darker green. Note that any Problem items are shown with a link and clicking this will take you to the Problems tab.

The buttons are:
New - create a new entry - a window will open allowing you to select the type of entry to be created. If it is something other than a visit (ie a note, a form, etc), then the new entry will be created under the currently selected visit. Note that the 'current visit' is the visit containing the currently selected item (which may be the visit itself or a note, form, medication etc item that is part of that visit).
With the exception of Visit and Problem records, records can be automatically locked from editing after a period of time. See Medical Record Locking below.
Edit - edit the selected item. If the Edit button is displayed, then you can edit the item - but for some things (e.g. an invoice item where the invoice has been finalised, or a Note that has been locked) the edit button will be suppressed because you cannot edit in this case.
Delete - delete the selected item - a confirmation window will be displayed. Again, if you can't delete the item, then the Delete button will not be displayed.
Print - print what is shown on on the screen (or preview it or email it)
Add Visit & Note - pressing this will generate a new visit entry (with Reason 'No Reason') and open the Create/Edit Note window so that you can add a note. This button should NOT be used to create a normal consult visit (for this you should use the Check-In button on the Workflow|Scheduling screen). It is intended for use when creating a note unrelated to another visit, say as a result of a phone call.
Import Flow Sheet Reports - imports Medical Records, Billing, Notes and Flow Sheet PDF reports from Smart Flow Sheet. Only displayed if Smart Flow Sheet is configured for the current Practice Location.

Problems

The Problems tab shows the details of the patient's problems. This tab mirrors the Summary tab display but shows the data grouped by problem rather than visit. Visits are shown with a link and clicking this will return you to the Summary tab.

The buttons are as follows:
New - create a new entry - a window will open allowing you to select the type of entry to be created. If it is something other than a problem (ie a note, a form, etc), then the new entry will be created under the currently selected problem. Note that the 'current problem' is the problem containing the currently selected item (which may be the problem itself or a note, form, medication etc item that is part of that problem).
Edit - edit the selected item. If the Edit button is displayed, then you can edit the item - but for some things (eg a invoice item where the invoice has been finalised) the edit button will be suppressed because you cannot edit in this case.
Delete - delete the selected item - a confirmation window will be displayed. Again, if you can't delete the item, then the Delete button will not be displayed.
Print - print what is shown on on the screen (or preview it or email it)

Reminders/Alerts

The Reminders/Alerts tab shows the details of the patient's reminders and alerts.

For details on the Alerts fields click here, for Reminders click here.

The buttons are as follows:
New - create a new alert or reminder
Edit - edit the selected item
Delete - delete the selected item - a confirmation window will be displayed

Documents

This shows the details of the patient's documents. As you can see below, there are 5 different types: Attachments, Images,Investigations, Letters and Forms. All of these except the latter support 'versions', ie previous revisions of the document.

The buttons are:
New - create a new document - a window will open allowing you to select the type
Edit - edit the selected document record (not the document itself - though see below). If the document has status Finalised you will not be able to edit the record.
Delete - delete the selected document - a confirmation window will be displayed. If the document has status Finalised you will not be able to delete it.
Print - if the selected item has an associated document template (which can be the case with an Investigation - see Administration|Types|Investigation) this will be presented for printing. Otherwise, if there is an attachment present, in .odt or .doc format, it will be presented for printing. If the document is other than an .odt or .doc file, it will be downloaded and can then be printed.
Refresh - (this button only appears when the selected document is a Letter) - refresh the document by regenerating it from its template - a confirmation window will be displayed.

Clicking on the entry in the Document column will cause the document to be downloaded and displayed. Note that for Letters the Document column shows two icons like . If you click on the right-hand one, the pdf file containing the letter will be downloaded and displayed. If you click on the left-hand one (or the name of the document) then the word processing document will be downloaded and you can open it in your word processor and save it and then edit it. (You need to save it as it is opened read-only.) After editing the file, you can then use the Edit button to edit the letter and upload the revised file.

Charges

This shows the details of the charges resulting from the patient's treatments. Note that this screen just displays information, there are no 'bottom buttons' to let you do things. It is provided so that you can check that everything you think should be charged for has been, and to check on past charges.

Prescriptions

The Prescriptions tab is where patient prescriptions are created and dispensed.

The buttons are:

New - create a new prescription
Edit - edit the selected prescription. If the prescription has been fully dispensed or has expired, it cannot be edited.
Delete - delete the selected prescription. If the prescription has been dispensed or has expired, it cannot be deleted.
Print - prints the selected prescription.
Dispense - dispenses the selected prescription. This displays a medication window that allows the Date, Expiry Date and Clinician to be selected. The Label and Quantity are fixed
Cancel Prescription - cancels the selected prescription, if it hasn't been fully dispensed or expired.

Communication

The Communication tab is used to display and log communication regarding the patient. Each communication may also be viewed via the customer. See Customers - Communications & Alerts for more details.

Medical Record Locking

By default, medical records are automatically locked from editing after a period of time. This is determined by the Practice setting Record Lock Period.

The following record types are automatically locked:

Addendum
Attachment
Attachment Version
Image
Image Version
Investigation
Investigation Version
Letter
Letter Version
Form
Medication
Note
Weight

An Addendum record can be used to annotate a Medication or Note record after it has been locked. These are displayed after the record in the history that they annotate. To do this, click on the Medication or Note record that you want to add an Addendum to and press the New button and select Addendum.

Note that the visit itself is not locked, and that if you desire, you can add a new note (or other item) to a visit whose other items have been locked. What you cannot do is modify the items that have been locked.

Investigations support some updates after they have been locked:

Reports can be added.
The existing report is versioned, if one is present.
The Reviewed flag can be changed, on the current and prior versions
The Result Status can be changed

Other locking exceptions include:

Medication, Investigation and document records linked to an invoice may be edited or removed via the invoice, until the invoice is finalised
Investigation and document records can be updated via the Document Loader
Medication, investigation, and document records can be removed from the patient history if the invoice is reversed.

Confirm Delete

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This is the delete confirm screen. Press OK to proceed, else Cancel.

Confirm New

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Depending on which tab of the Medical Records or Visit Editor screen that you have open, this window allows you to select the type of medical record entry, alert/reminder, or document to be created. Select the required one and press OK, else Cancel to abort.

For the Summary tab, the window is: (the partially visible last item is 'Weight')

For the Reminders and Alerts tab, the window is:

For the Documents tab, the window is:

Confirm Refresh

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This window is displayed when you press the Refresh button to refresh a letter from its template. Press OK to confirm, Cancel to abort.

If Version current document is checked, then when the letter is regenerated, the current copy will be saved as a version, otherwise it will be replaced.

Create/Edit Alert

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This is the screen used to create or edit a patient Alert. See Concepts|Alerts for background.

The fields are as follows:
Alert Type - select from those available - these are set via Administration|Lookups|Patient Alert Type
Priority - this displays the priority of the alert - see above link
Reason - a short version of the Notes text
Notes - the long version of the reason for the alert
End Date - the date on which the alert was ended (ie set to Completed status)
Status - can be either In Progress or Completed

Create/Edit Attachment

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This is the screen used to create or edit an attachment document in the patient's medical records. See Concepts|Documents for background. Note that although you can use this facility to attach an image file, it is probably better to use the Image facility for this.

The Versions tab shows the previous versions. Note that you can use the Add button to add another, but you can also use the Select button. If you use the Select button to attach another file, then the previous 'top' version will just be pushed onto the version list.

As you can guess from the above, there is no problem in adding the same file name twice. In fact although two notes.txt files have been attached, each in fact contains different text.

Create/Edit Form

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This is the screen used to create or edit a form document in the patient's medical records. See Concepts|Documents for background.

The fields are as follows:
Start Time - the date on which the entry was created - defaults to today
Description - any pertinent description
Status - this can be In Progress, Completed, or Finalised. In Progress implies that you are still working on this; Completed implies that you have finished - but the entry can still be editied; and Finalised means that it is really complete and can no longer be edited.
Printed - this box will be checked when the form has been printed
Form - select the form to print - these are the document templates that are of Type 'Patient Form'
Product - select a product if appropriate. This is here so that if the form selected is sensitive to the current product, the form can include product information. Thus, for example, we do not have to have a vaccination certificate for each type of vaccination - we can just have a general certificate that prints the name of the current product.
Clinician - the appropriate clinician - normally the form will display the clinician's name

Create/Edit Image

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This is the screen used to create or edit an image document in the patient's medical records. See Concepts|Documents for background.

Note that there is no problem in adding the same file name twice. Thus if your images arrive in files called img001.jpg, there is no problem if there is already an image imported from a file named img001.jpg.

Create/Edit Investigation

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This is the screen used to create/view/edit investigations. For background see Concepts|Investigations.

The fields are as follows:
Start Time - the date on which the investigation was initiated
Investigation Type - the type of investigation - these are set up via the Administration|Types|Investigation screen
Notes - you can enter any appropriate notes
Status - this will initially be 'In Progress' - for other settings see Concepts|Investigations
Order Status - the status of the order. This will initially be 'Pending' to indicate that the order has not been sent. For other settings see Concepts|Investigations
Clinician - the associated clinician
Report - use the Select button to add the results report to the investigation. Note that if there is an existing report and you add another, the first will be pushed down into the Versions tab. You can upload any sort of file at all. If you are using the automatic facility (see Concepts|Investigations) to attach investigation results, then you should not have to use the Select button to attach results.

The Print Form button is used to reprint the Investigation form.

The Versions tab is used to display and manage the versions of the reports. Normally the Add button is not needed - as discussed above you just use the Report|Select button to add a new version of the report. The display area shows the previous versions in a column format. Selecting a version causes its fields to be displayed (and these are the same as above). The column headings are:
Date - the date of the version
Description - this showns the Notes field
Document - this shown the results file - you can click on it to download and display it.

Create/Edit Letter

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This is the screen used to create or edit a letter document in the patient's medical records. See Concepts|Documents for background.

First lets look at the screen shot for a new letter:

The fields are as follows:
Start Time - the date on which the entry was created - defaults to today
Description - any pertinent description
Status - this can be In Progress, Completed, or Finalised. In Progress implies that you are still working on this; Completed implies that you have finished - but the entry can still be editied; and Finalised means that it is really complete and can no longer be edited.
Printed - this box will be checked when the letter has been printed
Clinician - the appropriate clinician
Template - select the template to be used - these are the document templates that are of Type 'Patient Letter'
Document - you DO NOT need to press the Select button when you are creating a new letter. Simply selecting the Template will generate the letter from the template and insert the appropriate information.

Now the edit screen. The senario is as follows: you created the letter as above. Then you decided that you needed to edit it, so on the Documents tab of the Medical Records screen, you selected the letter and then clicked on the actual letter to download it and open it in your word processor. You then saved a copy (as say Referral Letter-2), edited in the required changes and then saved it.

On the Medical Record screen you now press the Edit button to get the Edit Letter screen. You then press the Document Select button - this will open a browse window to allow you to select your 'Referral Letter-2' and upload it. The screen will then appear as below. The initial version has been saved as the previous version, and your new one as the new current version.

As intimated above, the Versions tab shows the previous versions. Note that you can use the Add button to add another, but you can also use the Select button. If you use the Select button to attach another file, then the previous 'top' version will just be pushed onto the version list.

There is no problem in adding the same file name twice. In the above example the file names were different but they could have been the same.

Parameters

If a template containing parameters is selected (i.e. Fill-In fields in Microsoft Word, or Input Fields in OpenOffice Writer), a window like that below will be displayed prompting for the values of those parameters. On OK, these will be merged with the document. Note that the order of the prompts cannot be specified, ie if the template has prompte P1, P2 and P3, these may be displayed on the screen in the order P2, P1, P3.

The parameters are normally text fields and hence you can use macros to enter the information.

Create/Edit Medication

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This is the screen used to create or edit a medication entry in the patient's medical records.

If the medication entry is being created as a result of invoicing the item, then this screen will only be displayed if the medication product entry has it's Dispensing Label option ticked. It is always displayed to edit the medication entry, or if the entry is being created via the New|Medication button on the Patients|Medical Records screen.

The fields are as follows:
Date - the date the medication record was created - defaults to today
Expiry Date - if a Batch has been selected, this represents the Batch expiry date. If not, you can enter the expiry date of the medication. Note that you can enter a relative date (e.g. 2m for 2 months from today).
Quantity - the quantity
Label - the label text- this will be initially set from the medication product record
Print Label - pressing this button prints the label using the template, 'Drug Label'
Medication - the medication product
Batch - the product batch. If selected, this determines the Expiry Date. The Batch dropdown displays all active batches of the medication at the current stock location. The batch with the earliest expiry date is shown first.
Clinician - the clinician
Dispensing Notes - these will be displayed if there are any

Note that if it is important to you that the Dispensing Notes be displayed when the item is added to the invoice but you would not normally print a label (and hence the product's Dispensing Label option is not ticked), you should edit the product to have the Dispensing Label option ticked, but either leave it's Label Text blank, or set to say 'No label required'.

Create/Edit Note

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This is the screen used to create or edit a note in the patient's medical records.

The fields are as follows:
Date - the date of the note - defaults to today
Note - the note text goes here. If needed you can change the size of the note window using the handle at the bottom left of the text window.
Clinician - the clinician

Create/Edit Prescription

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This is the screen used to create or edit a prescription. See Concepts|Prescriptions for background. In the picture below, the prescription has already been dispensed once so the 'Dispensing' tab is shown. If the prescription was being created the Dispensing tab would be absent.

The fields are as follows:
Date - the date on which the prescription was created - defaults to today
Expiry Date - the date on which the prescription expires. After this date, the prescription cannot be dispensed nor deleted. Note that this is totally separate from the Expiry Date set when you dispense the item - which is of course the expiry date of the dispensed medication. This date defaults to today plus the Prescription Expiry interval set for the practive - see Administration|Organisation|Practice. If you have not set this, then it defaults to zero and the Expiry Date will default to today.
Quantity - the quantity to be dispensed each time
Repeats - the number of repeats
Medication - the product
Label - the dispensing label text - this defaults to that set for the product. This will be the label when you actually dispense from this prescription.
Clinician - the clinician
Times Dispensed - the number of times that this prescription has been dispensed.

The Dispensing Tab shows the information for previous dispenses of this prescription.

Note that when you set up the prescription, you are functionally authorising the dispensing a total of (qty x (repeats+1)). Hence if you set the Quantity to 2 and the Repeats to 5, the total quantity being authorised is 12.

Note also that when the prescription is dispensed neither the Quantity nor the Label text can be altered. If these do need to be altered, this must be done by editing the prescription itself.

Create/Edit Problem

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This is the screen used to create or edit a problem in the patient's medical record. See Concepts|Problems for background. The following screen shows a problem being edited.

The fields are as follows:
Date - the date the problem was created - defaults to today
Presenting Complaint - the presenting complaint
Diagnosis - the problem diagnosis
Status - this can be Unresolved or Resolved
Resolved Date - the date on which the problem was resolved
Clinician - the associated clinician

Problem Presenting Complaint/Diagnosis selection

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These two screens are presented if you click the appropiate binoculars icon on the Problem edit screen. They allow you to select the Presenting Complaint or Diagnosis respectively. In both cases you can select from standardised VeNom codes or practice specific ones - the available sets are determined via the Administration|Lookups screen.

The Presenting Complaint selection screen is:

The selection fields are:
Type - this can be set to All or either 'Presenting Complaint' or 'Presenting Complaint (VeNom)'. All selects both.
Search - enter the text top search for. As per the example above, this does a 'contains' search rather than a 'starts with' search.

The Diagnosis selection screen is:

The selection fields are:
Type - this can be set to All or either 'Diagnosis' or 'Diagnosis (VeNom)'. All selects both.
Search - enter the text top search for. As per the example above, this does a 'contains' search rather than a 'starts with' search.

In both cases, you can click on the required item to select it and return to the Problem Edit screen or press Cancel to return without making a selection.

Create/Edit Reminder

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This screen is used to create and edit reminders. Normally reminders are created automatically by the system (ie as a result of invoicing an annual vaccination, the system will create the reminder for the next one), but they can also be created manually using this screen. Similarly, they are normally processed automatically by the Reporting|Reminders processing. However, in some circumstances you may want to cancel them or change their due date manually.

The fields are as follows:

Date - the date on which the reminder was created
Reminder Type - the Type of the reminder
Due Date - the due date (ie when the vaccination is due)
Status - this can be In Progress (ie active), Completed (ie the associated event, eg the vaccination, has occurred), or Cancelled. Normally the system will adjust the state to Completed (when the event occurs) or Cancelled (when the reminder becomes too old), but you can also change the state using this screen.
Reminders Sent - displays the number of reminder notifications generated
Last Sent - the date on which the last one was generated
Completed - the date on which the reminder was completed. Note that if the reminder is cancelled by the system, the date on which this happened is not shown here, is this is a Completed date, not a Cancelled or Completed date.
Error - if an error occurred the last time that the reminder was processed by Reporting|Reminders|Send All, this will be shown here
Product - the associated product
Clinician - the associated clinician

Create/Edit Visit

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This window is used to create or edit the patient's visit record. Note that if you are using the workflow facilities, and in particular the Consult button on the Workflow|Work List screen, then the visit record will be created for you.

The fields are as follows:
Start Date - the date on which the visit started - defaults to today
Complete Date - the date on which the visit was completed
Reason - the reason for the visit
Summary - an optional summary of the visit
Clinician - the clinician
Status - you can set this to In Progress or Completed

The Print button will print the complete visit information (ie including notes, medication, weight, etc) - not just the above information.

Add Problem to Visit

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This prompt is displayed when creating a new Problem:

New Problems can be added to the most recent Visit, or to a new Visit.

Click:

OK to add the Problem to the selected Visit
Cancel to cancel Problem creation

Create/Edit Weight

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This window is used to create or edit the patient's weight record.

The fields are as follows:
Date - the date on which the weight was measured - defaults to today
Weight - the weight
Units - the units - you can select Grams, Kilograms, or Pounds
Clinician - the clinician

New Medication Record prompt

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The New Medication Record prompt is displayed when creating Medication records from:

Patients|Medical Records|Summary
Patients|Medical Records|Problems

When Medication records are created this way:

the customer is not invoiced
the medication quantity selected does not change the stock level

If there is no need to invoice the customer, or change stock levels, click OK.

If the customer should be invoiced, then click Cancel, and add the medication via:

Customer|Charges
the Visit Editor