UC10 - Entering Treatment Records
- Jeff Duke
Description | Adding data into an active Treatment Sheet. |
|---|---|
Actor | Faculty, Resident, Intern, Tech, Student |
Privileges | Patients → View Treatment Sheet → Edit Treatment Records |
Triggers |
|
Preconditions | Active Treatment Sheet |
Steps | Ideal Workflow - Data captured in the same hour scheduled. |
Post Conditions |
|
Proposed Changes | New Functionality |
Specifications / Attachments |
|
Ideal Workflow
Open Patient Medical Record and Open the Treatment Sheet Tab, the active treatment sheet should be the default. The Treatment sheet contains all of the patient orders grouped by their categories. The table includes the treatment item’s name, last value, frequency, and time grid. The time grid will default to the current date and time, minus 3 hours plus 12hrs, giving the user a view of a 16 hours window.
Clicking on the time cell or cell in a given time column will open the Treatment Sheet entry dialog.
The dialog will open with the time selected based on the context of the click and defaulting to only treatment items that are due or optional (PRN). The header bar shows the date and time selected and the “Show Only Treatments Due” option. The bar has a background color to indicate if the treatments information being entered in past, present or future. Matching the red, yellow, and green colors of the time grid.
If the “Show Only Treatments Due” option is unchecked, the dialog will update and show all treatment items active on the treatment sheet.
Each row has an indicator and dropdown selector that shows the default actions. In this example to complete items due on schedule or add items that are as needed.
If viewing all treatment items, the default action for items that are not due or PRN, is to add additional information off schedule.
Data can then be added to multiple rows. Some items depending on type might be just confirming something has been done, like billing options in this example.
If a value is entered that triggers an alert there is an immediate icon and message that is displayed. Refer to Adding Treatment Items (Orders) for more information on configuring alerts.
Alerts can also be manually flagged.
On save, the time grid will update to show new record items.
The order item will highlight and show the alert icon if the last value is flagged as an alert. Rollover of the alert icon will show alert message. The time grid icon will alert show that item was flagged as an alert, regardless of it being the last value or not.
Adding results to overdue items
If clicking on the time grid on a time in the past, the edit dialog will open with existing value loaded. The header bar will show the date and time clicked on and will highlight with a red color.
The default is that all data will be entered under the assumption that the data or treatment was completed in the appropriate scheduled timeframe.
If data or treatment was completed at a different time then the user can select the appropriate action.
Add Additional Treatment Item will create a new treatment entry at the selected time and not change or satisfy the current item.
Off Schedule, Keep Existing Schedule will satisfy the current item, updating the time to the time selected. However, will not affect the future schedule treatment times.
Off Schedule, Update Schedule will satisfy the current item, updating the time to the time selected. This option will also reschedule future treatments at established frequency.
On save the time grid will update with the new information. If something is flagged as Off Schedule, the original timeslot will be flagged along with the selected time the treatment was completed.
Adding results early
If clicking on the time grid on a time in the future, the edit dialog will open with existing value loaded. The header bar will show the date and time clicked on and will highlight with a green color.
The default is that all data will be entered under the assumption that the data or treatment was completed in the appropriate scheduled timeframe.
If data or treatment was completed at a different time then the user can select the appropriate action.
Add Additional Treatment Item will create a new treatment entry at the selected time and not change or satisfy the current item.
Off Schedule, Keep Existing Schedule will satisfy the current item, updating the time to the time selected. However, will not affect the future schedule treatment times.
Off Schedule, Update Schedule will satisfy the current item, updating the time to the time selected. This option will also reschedule future treatments at established frequency.
On save the time grid will update with the new information. If something is flagged as Off Schedule, the original timeslot will be flagged along with the selected time the treatment was completed. If Update Schedule was selected the future treatment times will also be updated.
Adding in additional results not scheduled
From the entry dialog, unchecking the “Show Only Treatments Due” option will show all treatment items available on the active treatment sheet. If the item is not scheduled the default is that any entry is an additional result.
If more results need to be recorded in the same time slot, additional results can be added through the right click menu or the 3-dot menu.
Additional result can then be added. When reloading the entry dialog all results in the given time slot is loaded, including additional or duplicated treatment items. If there are duplicated results in a single hour timeslot, then user is presented with a time selector to set the actual result time. Otherwise, the hour time slot is used as the treatment time.
On Save the time grid is updated. The Treatment item will display the last result entered by datetime, and the time slot will display the last result by datetime in that hour.