Medical Records
One of the most important areas in the system, the Medical Records section allows control over all the records and history regarding a patient. To get to this area, click on Patients->Medical Records.
Once in the medical records section, you will see a series of tabs. Each of these allows you to view different aspects of the patient's history. There are also some tabs that allow you to control things such as reminders, alerts, etc. All of this is described below.
Summary
The summary section shows the top-level medical information that doctor's may want to look at first. This is a series of notes, and other elements of the patient record that compose the whole medical history for the patient.
The main grouping of this list is a visit. All medical records in this view must be associated with a visit. Generally, the workflow will create a visit for you, but sometimes you may need to create one manually. In order to create new items, including a visit, click "New" at the bottom of the screen. You will then be able to select the type of item you would like to create. Here's a brief list of things you can create in this screen:
- Attachment: This can be an attachment of any file to the record.
- Form: Forms are generally printed, and then filled out manually.
- Image: For attachement of any type of image, including animal photos, X-rays, et cetera.
- Investigation: Used for outside processes, such as bloodwork, etc.
- Letter: This is a document that would get printed out of the system and delivered to the customer.
- Medication: This is a medication. It permits printing of labels, etc.
- Note: This is where doctor's can add notes to the patient record.
- Problem: For taking note of a particular problem of a patient.
- Visit: The overall grouping item for all of the above.
Problems
It turns out that there is some structure underneath the overarching summary view above. The system is designed for doctors to create a "Problem" under their patient, and then associate notes directly with this problem. This is further useful because we can then track when the problems resolve. Once they resolve, they can be filtered and not shown any longer. This keeps what's being shown to the doctor relevant. It also makes sure the notes shown are directly linked to a problem. There can be no confusion regarding notes and medications, and what they are talknig about or designed to treat.
Tip: When you create a problem, and associate notes to it, they will all automatically show up in the summary view. The same goes for many documents that you can access from other places in the system.
To create a problem, click "New" and fill in the information. You can add notes and/or medication at the same time.
Reminders/Alerts
While these two things are grouped together, they have very diffirent functions in the system. They're discussed separately below.
Alerts
Alerts are for flagging things that other staff at the practice might want to know about a patient, as soon as the patient walks in the door. Alerts can be configured (by your administrator) to have any text associated with them that you want, and the same goes for color. When you add an alert, it will show up in the current patient information area.
The screenshot to the right shows the alert "Aggression", which may or may not be setup on your system. Also note that it's color coded in red making it stand out. As soon as someone clicks on this client, presumably at check-in time, they will be able to see the alert. This will help keep the staff aware of any special precautions that need to be taken with this patient.
In orde to create a new alert click "New" and then select "Alert" from within the Reminders/Alerts tab.
Reminders
Reminders are useful for inside the practice, and for generating continued business from outside the practice. The general purpose of a reminder is to make sure that customers and doctors are aware of when a patient is due for a certain procedure, checkup, test, or any other thing.
Internal to the system, there are three values that are associated with a reminder. Your system administrator can help you set these values for each reminder.
- Reminder Interval: When added automatically, when should the next due date be?
- Sensitivity Interval: How long before (and after) the reminder, should we note it as relevant.
- Cancellation Interval: How long after the reminder, should we begin ignoring it?
Note the bell symbol in the picture above. That bell means that there are reminders for that patient. If you were to click the bell, you would see a list of reminders, color coded according to the above. They are coded as follows:
- Green: Not due yet.
- Yellow: Within the sensitivity interval above.
- Red: Late.
Printing reminders can be accomplished through the Reporting section. More discussion of this can be found there.
To create a new reminder, click "New", then "Reminder", and fill in all the fields. If there's a particular reminder that you don't see there, your system administrator can add a new reminder for you.
There are many different kinds of reminders, and they behave differently (depending on your configuration)! Some reminders can be set to be added to the patient record automatically when you sell a particular item. For instance, when you bill a customer for an annual examination, you can configure the system to automatically create a reminder for the next annual examination. Not only will the system create a new one, but it will mark the current one as completed.
We won't dive any deeper into this subject because a lot of it ends up being hidden from the users, and hence is much more relevant to the administrator. For now, just understand that some reminders get created automatically, and some don't. Work with your administrator to configure how they all behave.
Documents
The documents area is a way to see all documents associated with the current patient. Here you can create new documents, edit existing documents, and print any document.
Charges
The charges area shows all the invoice items that are associated with the current patient. This can be useful if you'd like to see what this patient has been charged for in the past.
Tip: The charges list displays charges and credits. To see just invoices or just credit, click on the "Types" pull-down and select one or the other.
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