Medical Records and Consultations
Every healthcare professional knows the importance of medical records. They are the foundation of patient care, guiding clinicians in making timely decisions. Today we can get into the nitty gritty of managing and recording medical records and consultations. Let’s dive into the details of these features to see how they help document patient care.
Consultation Viewer
Our software has a Consultation Viewer for easy access to patient consultations. Located in the general "Records" section and the "Patient Chart" this viewer allows users to see all consultations for a patient. In reverse chronological order it shows each patient’s encounters so clinicians can see the patient’s care journey.
Multi-Patient View: Toggle between individual patient consultations or view all patient records at once.
Filtering Options: Search by patient name, specific date ranges or keywords to find past consultations quickly.
Preview Modes: Users can change how consultations are displayed using the "View" settings to suit their preferences.
Editing Consultations: To edit a record double click on any consultation to edit directly within the system.
Adding New Consultations
Adding a new consultation is easy. A "New" button in the Consultations viewer takes users into the Consultation Editor where encounter details are recorded.
Fields:
Title: Brief description of the visit e.g. "First Consultation."
Tags: Custom tags like "preop" or "postop" for tagging.
Condition and Diagnoses: Select from a list of preloaded ICD codes for coding and diagnosis tracking.
Treatments: Document any treatment procedures, use standard codes for consistency.
Medication: Specify prescriptions, option to dispense or refer to external pharmacy.
Save: Click "Save and Close" when done and the system will save the new consultation for future reference.
Customizable Consultation Templates
The Consultation Editor has customizable templates so each medical professional can tailor their input fields. Users can create their own layouts and hide or show fields based on their personal or institutional preferences. These fields include patient complaints, clinical findings, diagnoses, treatments and medications.
Layout Customization: Users can show or hide fields so only relevant information is displayed.
Field Options: From patient history to drug interactions and allergies fields can be configured for specific data requirements.
Template Flexibility: Templates can be changed as patient needs change, new clinical guidelines or treatments.
Real-Time Updates
Our software provides real-time updates across patient records so any change is available to all authorized users. Whether it’s a new diagnosis, updated treatment or additional documentation this real-time functionality means medical teams are working with the latest data.
Instant Synchronization: Data is available across departments in real-time, no lag, no coordination issues.
Automated Status Refresh: As updates are made the previous version of the record becomes outdated so there’s no chance of using old information.
Embedded Documents and Images
One of the features of the system is the ability to embed documents and images into consultations to add more detail to each patient encounter.
Document Integration: Upload images, PDFs or Word documents to any patient record.
Image Capture: Users can capture images from connected devices (e.g. cameras, scanners) and link to the consultation.
Clinical Detail: Photographs of wounds, imaging results or even scanned lab documents for more detail.
Flexibility in Organisation: Attachments will be stored under "Patient Documents" or "Patient Images" for quick access in future consultations.
Drug Interaction Checks and ICD Codes
With drug interaction checks embedded our software helps clinicians identify potential conflicts in prescribed medications. Plus it has standardized ICD (International Classification of Diseases) diagnosis and treatment codes so documentation is consistent and recognized.
Drug Interaction Alerts: As medications are added the system will cross check for interactions and alert the clinician if there’s an issue.
Standardised Coding: Clinicians can choose from ICD-9 and ICD-10 codes for diagnoses and procedures for accurate billing and insurance claims.
Custom Diagnoses: Manual input for unique cases where standard codes don’t apply.
Patient Forms and Questionnaires
One of the features is the patient forms within the Consultation Editor. Customizable and reusable these forms will reduce data entry and typing.
Predefined Forms: Choose from various templates, from standard checklists to in-depth assessments.
Customizable Fields: Clinicians can modify forms to suit departmental or individual patient needs.
Quick Fill Options: Some fields are pre-configured to auto fill based on typical data so less typing during repetitive tasks.
Simplified Workflow
Our system is designed to support clinical workflows by taking administrative burden off healthcare professionals. It consolidates tasks like documenting consultations, prescribing medications and managing treatment plans into one interface.
One Click Actions: Functions like "Prescribe" or "Add Treatment" are available in the consultation editor so you don’t have to navigate back and forth.
Complete Documentation: All aspects of the consultation from patient complaints to billing are stored in one view in the "Activities" section.
Seamless Transition: Move between the patient’s current visit and past records for comparison to aid continuity of care.
Importing Data: Consultations, Diagnoses and Treatments
Our software allows you to import patient data from CSV files to migrate historical data into the system.
CSV Import for Consultations: Import consultation records in bulk using a standard template that matches the system’s fields.
Diagnosis Codes Import: Import ICD-9 and ICD-10 codes to ensure consistency in diagnosis documentation.
Treatment Code Import: Treatments can also be imported in bulk just like diagnoses to standardise entries across departments.
Consultation Locking
For security and accountability consultations can be locked by the medic who is responsible for the consultation so no one can make changes after approval.
Medic Locking: Only the original medic or an administrator can lock or unlock a consultation.
Audit Controls: Locked consultations will have a unique icon so it’s clear which records are finalised.
Permissions Management: Administrators can configure permissions to grant or restrict consultation editing rights based on roles.
Printing and Exporting Consultations
For patient handouts or filing purposes the system allows you to export consultation details in customisable formats. If you need printed records the program allows mail merge with templates to output professional documents.
Mail Merge with Templates: Customisable MS Word templates for formatted patient facing documents.
Selective Printing: Print only what you need—diagnoses, treatment plans or prescription instructions.
Editable Templates: Modify existing templates to match current standards or institutional requirements.
The detailed record keeping in our system gives healthcare professionals a reliable and configurable tool to document every step of patient care. By centralising medical records, consultations and essential health data this system allows providers to have a complete view of patient health, streamline workflows and make data driven decisions that benefit patients and healthcare teams. With this level of organisation and accessibility you can focus on what matters most—patient care.
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