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Templates for filling out a medical record


Templates for filling out a medical record

Tabs

In the directory "branches" bottom is "tabs" , with which you can create templates for filling out a medical record.

Template Tabs

On the right, the tabs have special buttons with which you can scroll through the tabs, or immediately go to the one you need. These buttons are displayed if all tabs do not fit.

Tab navigation buttons

Templates are compiled separately for each medical department. For example, there will be some templates for therapists, and others for gynecologists. Moreover, if several doctors of the same specialty work for you, then each of them can set up their own templates.

Complaints

First, select the desired section from the top.

Department selected

Then from the bottom pay attention to the first tab "Possible complaints" .

Possible complaints

First, at the appointment, the doctor asks the patient what exactly he is complaining about. And his possible complaints can be immediately listed, so that later you don’t have to write everything from scratch, but simply select ready-made complaints from the list.

All phrases in the templates are written in lowercase letters. When filling out an electronic medical record at the beginning of sentences, capital letters will be placed by the program automatically.

Complaints will be displayed in the order you specify in the column "Order" .

General practitioners will listen to some complaints from patients, and gynecologists - completely different. Therefore, a separate list of complaints is compiled for each unit.

General and personal templates

General and personal templates

Now look at the column "Employee" . If it is not filled in, then the templates will be common to the entire selected department. And if a doctor is specified, then these templates will be used only for him.

General and personal templates

Thus, if you have several therapists in your clinic and each considers himself more experienced, they will not disagree on templates. Each doctor will make his own list of complaints from patients.

Description of the disease

The second tab contains templates for describing the disease. In the Latin used by doctors, this sounds like "Anamnesis morbi" .

Description of the disease

Templates can be composed so that the first phrase can be chosen to begin a sentence, for example, ' Sick '. And then with the second click of the mouse, already substitute the number of days of illness that the patient will name at the appointment. For example, ' 2 days '. You get the sentence ' Sick for 2 days '.

Description of life

The next tab contains templates for describing life. In Latin it sounds like "Anamnesis vitae" . We fill in the templates on this tab in the same way as on the previous ones.

Presence of diseases or allergies

It is important for the doctor to ask the patient about "previous illnesses" and the presence of allergies. After all, in the presence of allergies, not all prescribed medications can be taken.

Presence of diseases or allergies

Current status

Further at the reception, the doctor must describe the patient's condition as he sees it. It's called ' Current Status ' or in Latin "status praesens" .

Presence of diseases or allergies

Please note that components are also used here, from which the doctor will make three sentences.

Survey plan

On the tab "Survey plan" physicians will be able to compile a list of laboratory or ultrasound examinations that they most often refer their patients to.

Survey plan

Treatment plan

On the tab "Treatment plan" healthcare professionals can make a list of drugs that are most commonly prescribed to their patients. In the same place it will be possible to immediately paint how to take this or that medication.

Treatment plan

Treatment results

On the last tab, it is possible to list the possible "treatment results" .

Doctor templates for letterhead for printouts of test results

Doctor templates for letterhead for printouts of test results

Important If your clinic prints the results of various examinations on letterhead, you can set up physician templates for entering examination results.

Doctor templates for various individual medical forms of laboratory tests and ultrasound diagnostics

Doctor templates for various individual medical forms of laboratory tests and ultrasound diagnostics

Important If the medical center does not use a letterhead for printing out the results, but various primary medical forms, then you can set up templates for the doctor to fill out each such form.




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