Patient Record Improvements

Add additional visualization of patient medical records and new functionality in TPR/vitals, SOAPs, MPL/diagnosis, treatment sheets, patient lists. Part of these changes will be to organize information better with a logical structure.

Adding in new tabs and organizing information

Starting with the Summary tab moving down the tabs into more detailed information and/or workflows.

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• Summary Tab - Show active list of high-level data about the patient.

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  • Demographic

  • Alerts

  • Visits

  • Appointments

  • Reminders

  • Master Problem and Diagnosis

  • Prescriptions

  • Vaccinations

  • Most recent Labs and Imaging

• Visits Information - Visit based medical records grouped in a structured medical record groups in descending order inside of each group.

• Timeline Tab (New) - Displays medical record information in reverse chronological order. Each row is a unit on information like, history document, request, daily SOAP, client communication, etc.

• Treatment Sheet Tab (New) - Displays treatments sheets in sub tabs that are active and a history tab of previous sheets. Treatment Sheets are designed for tracking medical care while the patient is hospitalized. Treatment sheet orders are displayed in categories based on type of data.

• Prescription Tab - Displays the prescription history in sub tabs grouped by type and/or status.

• Patient Details and Contacts Tab - Reorganized the details and contacts tab into a single tab, moving documents and notes to a separate tab.

• Documents and Notes Tab - Rearrange these tabs from the current details tab to provide more working space.

• Group Patient and Billing Package Tabs - will dynamically show or hide based on usage.

   

Custom TPRs/Vitals

Update the TPR/Vitals data structure and setup, so each vital or observation is an independent object. The setup will be more consistent and similar to result setup. Each item will having a data type and other settings to govern display and data entry. Each item will be organized into user defined categories and will be assigned a section of the medical record where they will be displayed. Click to see more details on Custom TPRs update.

SOAP as a Document

Moving the SOAP entry workflow to the digital document. This will allow for a more standardized SOAP template by service or case. This will also make it quicker and easier to add all of the SOAPing elements to the medical record. Also, by adding the SOAPing elements to the digital document other document elements can be intermixed on the document, like vitals or other physical data points. Click to see more details on SOAP as a Document updates.

MPL, SOAP Problems, and Diagnosis

Updating the MPL, SOAP Problems and the Diagnosis relationship. Currently the MPL and Diagnosis are independent workflows. Problems added through SOAPs and the Episode automatically sync to the MPL. Diagnoses are only managed and viewable through the Episode. In the updated workflow Diagnoses would also automatically be added to the MPL list. Problems can be Merged into Diagnosis and Diagnosis can also be added as a problem to be SOAPed. MPL items will be flagged as a Problems or Diagnosis and use the standard coding data structure to enforce standards of diagnosis items. Click to see more details on MPL, SOAP Problems, and Diagnosis updates.

Patient Timeline

Adding a new view to the patient medical records based on time of entry. All medical record actions, document, requests, vitals/observation, client communication, billing, etc. will be viewed in a chronological timeline. Each row in the timeline will have an icon and color coded by type of information. Items can be added and edited by expanding and/or opening them in a dialog. There will be filtering and sort options available. Click to see more details on Patient Timeline feature.

Patient Treatment Sheets

Adding a new feature to add inpatient care through time-based orders and treatment management. This new feature will add the ability to create orders for reoccurring treatment or data entry. Items like Vitals, Observation, SOAPs, Medications, Billing, etc. can be added with a frequency and quantity. Each orderable item will have setup to define data types, flagging, alerts, instructions, etc. Orderable items will be grouped in categories and assigned a medical record section, so data can be displayed correctly in the other existing views. Click to see more details on Patient Treatment Sheets feature.

Digital Document Improvements

Adding new document elements and adding dynamic data entry ability based on time or group patients. Click to see more details on Digital Document improvments.