Medical Record Setup
- Cathy Allison
- Rick Eggleston (Unlicensed)
This page was originally created for VetView 2.1. It has been updated on 9/9/2024 to reflect changes made in VetView 4.0 and later.
Medical Record Setup Tab
The Medical Record Setup tab is where you customize the sections of the medical record, as well as certain features on the patient record. Because VetView can be tailored to your hospital's existing workflows and terminology, some setup is required to get those unique values added if they were not imported through migration. This flexibility also allows you to change the medical record and the workflows as your hospital's needs change - new service areas and new compliance rules can be accommodated without a programmatic change in many cases.
Medical Record Category Setup
Medical Record Categories are the "folders" inside each patient record. The episode is split into these categories. Some categories are hard coded, such as personnel and diagnosis. Other sections can be added and adjusted to match your digital document structure.
This section also allows you to display or hide each section of the medical record from the Hospital Portal.
Add Medical Record Category
Click on the Add Med Rec Category button to start creating a new section on patient records.
Field | Description |
|---|---|
Label | The name of the medical record category. This should be short and clear. It will appear as the header for the section on the medical record. |
Description | A longer description of the medical record category. This part is not visible on the patient records, but can be helpful for keeping sections unique. |
Type | If this new category should appear as part of one of the hard-coded sections of the medical record, it can be selected here. If this is going to be a Catalog Item only category, then the Type can be left unfilled. |
Active Flag | If a medical record category is no longer going to be used on patient records, it can be disabled. Categories cannot be deleted once they have been added and used in a patient record, to preserve historical information. |
Owner | At what point the owner may see documents and requests added to this medical record category on the Client Portal. Note that this is different than the episode events, which send the communications on a push to an email address or fax number. This is passive visibility if they have access to the portal. The options are Never, Discharge, and Anytime. Only Complete and Verified documents are ever visible. |
RDVM/Clinic | At what point the RDVM or Clinic may see documents and requests added to this medical record category on the Client Portal. Note that this is different than the episode events, which send the communications on a push to an email address or fax number. This is passive visibility if they have access to the portal. The options are Never, Discharge, and Anytime. Only Complete and Verified documents are ever visible. |
The Medical record categories can be sorted on the patient record using the Move Up and Move Down buttons. (Sorts may not be immediately visible when the category is first added and will require a reload of the page.) Select the line you want to adjust and move it relative to the other parts of the record. Since only categories included in the base episode type are immediately visible for a new visit, the sort will only impact new categories that are added as the episode progresses.
This list is also mirrored on the left hand panel of the patient record, which includes the episode date filters as well as the category filters.
Medical Record Transfer Reasons
This section pertains to the physical Medical Record that is stored in your hospital records department. Under Medical Record Tracking, you can have a custom specified reason for a user to take out a medical record, such as for a research project. VetView allows you the flexibility to set these reasons as individual service areas as the location where it will be temporarily stored, or any other reason you might find necessary to check out a physical record.
Add a new Transfer Reason
Click on the Add button to create a new transfer reason. Enter in the Reason, and a detailed description. Click on Save to add the reason. It will immediately become available on the Medical Record Tracking screen once saved.
Reasons that will no longer be necessary can be set as Inactive. While these reasons cannot be deleted (to preserve historical data), inactive reasons will disappear from the Tracking screen going forward.
Comm Log Setup
This section allows you to create a new Mode of Communication on the patient record. As technology changes and you want to experiment with your communication options, you can add the new options into VetView. For example, if you want to try using Facebook Messenger service, it could be added as a communication type here.
Add New Communication Type
Click on the Add button to create a new mode of communication. Enter in the name of the new method, and click on Save.
The new mode of communication will become available on the Communication Log on the patient record.
Discharge Setup
VetView allows you to customize your Discharge statuses to match your hospital's workflows. The Discharge status is also tied in to certain automated events, and one of those triggers is an automatic deceased date if your patient is discharged under a deceased status. (Discharge can also trigger an automated sex change, but that is tied into a Document with that feature turned on, not the Discharge Status itself.)
Add a new Discharge Status
Click on the Add button to add a new Discharge status.
Field | Description |
|---|---|
Status | The name of the status as it will appear in the drop down menu on the Discharge window from the patient record. |
Deceased Flag | This discharge status should mark the patient as deceased under Patient Details, with the discharge date as the deceased date. The discharge status will display a warning that the patient will be marked as deceased if you proceed. |
Default | The default discharge status for all patients. There can only be one default for the hospital, so setting this flag will change all other Default flags to No. This is the Discharge status that will load on the Discharge window automatically, but it can be changed to any other status manually. |
Active Flag | This discharge status is currently active and available. Discharge statuses cannot be deleted once they are added, but you can turn off the flag for any which will no longer be used. |
TPR Setup
This has been moved to a new TPR Setup screen in version 5.0. See: TPR Setup in 5.0
Although VetView does not allow for customization of the TPR layout on the medical record prior to 5.0, you can customize the minimum and maximum accepted values, and add notes regarding each of the values. This can be useful from a teaching perspective for students who may not be familiar with the normal ranges for these, and it can also prevent errors made by typos.
Problem Setup
The Problem setup tab allows you to set the Value List (from the Value List setup under Catalog Setup) that Problems can be pulled from. You can also give the option to allow problems to be "free text" rather than only from the Value List that you set.