Medical Records

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 eight different screen shots below, one for each of the tabs: Summary, Problems, Reminders, Alerts, Documents, Charges, Prescriptions, and Communication. For patient insurance, see Insurance.

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.
Search - performs a case-insensitive search on patient records for the input text. The following fields are searched:

  • notes and addenda
  • record type
  • clinician, if the clinician is being displayed
  • batch number, if batches are being displayed
  • medication product name and label
  • invoice item product name
  • investigation type and identifier
  • document name
  • problem presenting complaint and diagnosis
  • weight

Note that Visits will always be displayed, even if there is no match.

Product Type - searches for records with the products with the specified Product Type(s). Product Types can be selected from a list, or by entering a partial name in the text field. The following records are searched:

  • Customer Invoice Item
  • Form
  • Investigation
  • Letter
  • Medication

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
Mail - email what is shown on on the screen
Add Visit & Note - pressing this will generate a new visit entry and open the New Visit & Note window so that you can add a new Visit and 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 Search field works the same as in the Summary tab, with the exception that both Problems and Visits will always be displayed, regardless of the search criteria.

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
Mail - email what is shown on the screen

Reminders

The Reminders tab shows the details of the patient's reminders.

For details on the Reminders field, click here.

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

Alerts

The Alerts tab shows the details of the patient's alerts.