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Maintaining an electronic medical history


Maintaining an electronic medical record

Doctor's schedule

Doctor's schedule

Maintaining an electronic medical record is easy for every doctor without exception. Each doctor immediately sees in his schedule which patient should come to see him at a certain time. For each patient, the scope of work is described and understandable. Therefore, the doctor, if necessary, can prepare for each appointment.

Paying patient

For the doctor not to take money

For the doctor not to take money

By the black color of the font, the doctor can immediately see which patients have paid for their services . Many clinics do not allow doctors to work with a patient if the visit is not paid.

Many medical institutions even ask to build protection into the program. For example, to prevent a doctor from printing a patient admission form if there is no payment. This allows you to exclude the acceptance of money by the doctor bypassing the cash register.

Switching to an electronic medical record

Switching to an electronic medical record

If everything is in order with the payment, the doctor can start filling out the electronic medical record. It is also called 'electronic patient record'. To do this, right-click on any patient and select the ' Current History ' command.

Switching to an electronic medical record

The current medical history is the medical records for the specified day. In our example, it can be seen that today this patient is registered with only one doctor - a general practitioner.

Paid service

Doctor working on a tab "Patient's medical record" .

Adding information to a patient's medical record

Initially, there is no data there, so we see the inscription ' No data to display '. To add information to the patient's medical record, right-click on this inscription and select the command "Add" .

Filling in an electronic medical record by a doctor

Filling in an electronic medical record by a doctor

Complaints

A form will appear to fill in the medical history.

Filling in an electronic medical record by a doctor

The doctor can enter information both from the keyboard and using his own templates.

Important Earlier, we described how to create templates for a doctor to fill out an electronic medical record.

Important Now let's fill in the ' Complaints from a patient ' field. Look at an example of how a doctor fills out an electronic medical record using templates .

Saving and reopening the medical history

We filled out the patient's complaints.

Completed patient complaints

Now you can click on the ' OK ' button to close the patient's record keeping the entered information.

Saving the entered information in the electronic patient record

After the work done by the doctor, the status and color of the service will change from above.

Color services in the medical history after the doctor's work

Tab at the bottom of the window "Map" you will no longer have ' No data to display '. And the record number will appear in the electronic medical record.

Record number in the electronic medical record

If you have not finished filling out the electronic patient record, just double-click on this number or select the command from the context menu "Edit" .

Editing an electronic medical record

As a result, the same electronic medical record window will open, in which you will continue to fill out patient complaints or go to other tabs.

Completed patient complaints

Description of the disease

Working on the ' Description of the disease ' tab is carried out in the same way as on the ' Complaints ' tab.

Description of the disease

Description of life

On the tab ' Description of life ' there is an opportunity in the same way to work with templates first.

Description of life

And then the patient is also interviewed for serious illnesses. If the patient confirms the transfer of a disease, we mark it with a tick.

Description of life

Here we note the presence of an allergy to medications in the patient.

If some value was not provided in advance in the survey list, it can be easily added by clicking on the button with the ' Plus ' image.

Current status

Next, fill in the current status of the patient.

Current status

Here we have compiled three groups of patterns that add up to multiple sentences .

Templates for the doctor to fill in the current status of the patient

The result might look like this.

Using templates to fill in the current status

Diagnoses. International Classification of Diseases

Important If a patient comes to us for an initial appointment, on the ' Diagnoses ' tab, we can already make a preliminary diagnosis based on the current state of the patient and the results of the survey.

Treatment protocols

Important After pressing the ' Save ' button when selecting a diagnosis, a form for working with treatment protocols may still appear.

Survey plan

Important If the doctor used a treatment protocol, then the ' Universal Accounting System ' has already done a lot of work for the medical professional. On the ' Examination ' tab, the program itself painted the patient's examination plan according to the selected protocol.

Treatment plan

On the ' Treatment plan ' tab, work is done in exactly the same way as on the ' Examination plan ' tab.

Treatment plan

Additionally

The ' Advanced ' tab provides additional information.

Result

' Treatment result ' is signed on the tab with the same name.

Print the patient's visit letterhead

Print the patient's visit letterhead

Important Now is the time to print out the patient's visit form , which will display all the work of the doctor in filling out the electronic medical record.

Important If it is customary in the clinic to keep the medical history also in paper form, then it is also possible to print the 025/outpatient form in the form of a cover page, in which the printed patient admission form can be inserted.

Work in the program of a dentist

Work in the program of a dentist

Important Dentists work differently in the program.

Viewing the medical history

Viewing the medical history

Important See how convenient it is to view the medical history in our accounting system.

Mandatory medical reporting

Mandatory medical reporting

Important The ' USU ' program can automatically complete mandatory medical records .

Working with goods and materials

Working with goods and materials

Important When providing services, the clinic spends certain accounting of medical goods . You can consider them too.




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