- By clicking on the Clinical chart tab, we could see the EMR screen of the Patient. It consists of different clinical components: Examination, CPOE, eRx, Surgery, and Summary. Here users can add Patient’s data in all components under the tabs for OP and IP.
- In the upper left corner, the user can find two tabs: Orders and Documents.
- Users have to save the data in every tab; else, it won’t reflect in the summary tab.
- Examination: In this tab, we can enter the Patient’s history, general examinations, investigations, vitals, etc
- When we add data in the Examination tab and move to another tab without saving it, that data won’t be reflected in the examination tab, and it will get deleted automatically. You will see an alert message like “please save the data to prevent data loss” on screen to avoid this.
- CPOE: This user can add Lab & Radiology and Clinical services by clicking on “Add test/Panel.”
- If the user adds services and moves to other tabs, these services will be added to the draft, and we don’t need the services repeatedly.
- The services added in CPOE will be automatically reflected in the OP Billing Service recording screen for OP patients. After paying the amount, services will be reflected on the respective diagnostics module page. For IP patients, it would be based on the settings.
- Whatever flow is going in the lab will be updated in the “orders tab” for OP patients. For IP, it will show as results are pending.
- When we add services in CPOE. The date and time of each test recorded against the Patient in the discharge summary print.
Settings for IP patients:
Settings are adjusted depending on whether the Officials want the Patient to pay immediately for each diagnostic Order (Individual), or would the amount be settled in the final bill at the time of patient Discharge (Final)?
- When the user selects the service amount to be settled in the final bill, the services added in CPOE should automatically be reflected in the respective diagnostics module page.
eRx :
- In this, users would add drugs for OP and IP patients. These drugs will be automatically reflected on the pharmacy screen.
- After adding drugs, you need to save them; those drugs will be saved in draft and won’t be reflected in the pharmacy.
- Users can select Telugu instructions in frequency if required.
- An ex-user can see different tabs: Prescription, Protocols, and Favorites.
In the Prescription tab: The users can add drugs by clicking on the “Add drugs.” After adding drugs user can give general instructions, internal comments, and Instructions for the pharmacy.
- Here user also has the option to print the prescription or not. As well as user can also send the prescription to the external pharmacy. To do this user has to enter the location of the external pharmacy, Name, Mobile Number and send/cancel.
In Protocols tab: The user can add drugs according to the diagnosis by clicking on “Add drugs”
In the Favorites tab: The users can add their favorite drugs.
Surgery: In this user will see different tabs, which are Pre-op, Operation, and Post-op, Upload.
Pre-op: In this user can add or edit Lab and Radiology tests. Here we can also schedule the surgery by filling in some mandatory details: surgery name, date, OT room, and doctor’s name. As well as Anesthesia and patient consent details.
Operation: In this user can fill some other mandatory details, which are Assistant details, Operation notes, Anesthesia details, and others.
Post-op: In this user can fill Post-operative care mandatory details, which are Assessment of wound site/dressing, Diet, Type & rate of IV fluids, etc.
Upload: In this user can upload the Patient’s required documents. Here, users can drag and drop the documents, give the document name, and provide descriptions.
Summary: In this user can find the complete clinical components data of the Patient, and also user can edit the Patient’s data and save it. Here users can also share the data with other doctors by clicking on the share tab.
- By clicking on Expand all option user can see the filled Patient’s data and take the printout of the data.
- Users can also untick the unnecessary components and take the print accordingly.
- Here users can also schedule the following update.
- If the user clicks on the Save button in the summary tab and makes any changes in other tabs, then the updated data won’t be reflected in the summary tab.
- OP – In the Discharge type drop-down user can see OP CASE SHEET, DEATH SUMMARY. The user will select accordingly and give a discharge summary.
- IP- In the Discharge type drop-down, the user can see DISCHARGE SUMMARY, LAMA, DAMA, DEATH SUMMARY, DISCHARGE ON REQUEST, and select accordingly give a discharge summary.
Close case: After finishing the clinical assessment and giving the prescriptions we can close the case by clicking on the close case option if there is no requirement of admitting the patient.