Patient History and Medical Records Overview

Medical Records and Patient History

"Your medical records tell a story, not just about health but about your life, values and choices." This is the philosophy that underpins our medical records system, a dynamic, customisable and accessible patient history. In this article we’ll take you through the key features of our software that capture every aspect of a patient’s history - family, social, surgical and beyond - while allowing full customisation of fields and forms.

Patient History Management

In our software patient history is integrated into both the patient chart and editor sections. This allows healthcare professionals to access, review and update patient history at any point during a patient interaction.

• Integrated Access: Patient history can be accessed directly from the patient’s chart or through the patient editor. This means clinicians can refer to key details while discussing treatment or history with the patient.

• Editable Fields: Each section of the patient’s history - medical, social, family or surgical - is editable in real time so information stays current throughout the patient’s journey.

• User Permissions: Access controls can be set by user role so sensitive information is secure and only visible to authorised users.

Family, Social and Surgical Histories

Our system goes beyond standard history tracking by supporting additional histories such as family, social and surgical, each with customisable fields. These histories provide a full view that is essential for personalised and preventative care.

• Family History: Record hereditary conditions that may impact treatment decisions. Family history fields are marked as “Unique Value Fields” so they carry over across visits for continuity of tracking.

• Social History: Social factors - lifestyle choices, occupation and habits - are part of the patient profile, providing valuable insight into non-medical factors that impact health.

• Surgical History: Surgical history tracks past procedures, complications and outcomes, which are crucial for pre-surgical assessment or planning new procedures.

Each history section can be expanded or customised to suit the specific needs of the practice so all relevant aspects of the patient’s background are recorded.

Custom History Templates

Our software allows clinics to create custom history templates. This flexibility is key for practices that need specific information fields or unique layouts, so they can design history forms to suit their exact workflows and patient demographics.

• Field Template Designer: With the Field Template Designer users can create fields with specific parameters - text types, integer values or dropdown selections - so data entry matches clinic standards.

• Unlimited Custom Fields: Add new fields or edit existing ones, choose from text, numeric or multi-line text for more detailed notes.

• Template Cloning and Editing: Users can clone existing templates to use as a base, add, remove or rename fields as required for specific histories so it’s quick to adapt without having to set up again.

These templates allow healthcare teams to capture only the data that matters to their practice, for a better experience for patients and providers.

Timeline for Chronological Viewing

The Timeline in the patient chart shows a patient’s entire medical history in chronological order so it’s easy to navigate past medical events. This is especially useful for clinicians when reviewing complex cases or tracking changes over time.

• Chronological Records: Each entry is displayed in sequence so clinicians can see patterns in health outcomes and assess previous treatments.

• Click-to-Edit: Historical entries are not just viewable but also editable from the timeline so users can add or correct information if needed.

• Single Screen Access: The timeline consolidates everything from consultations to medication changes so you don’t have to switch between screens and have a full view of the patient’s journey in one place.

Adding and Managing New Records

New records can be added to a patient’s history with a simple “Add New” function. From consultations to lab results, all data is under the Activities section so you have a full view of the patient’s encounters.

• Full Records Management: Users can add consultations, prescriptions, diagnoses and treatment notes from the Activities viewer.

• Customisable Layouts: These records are shown in a layout that can be customised by the clinic, with options to group and filter by doctor, date or type.

• Record Editing and Deletion: Records can be edited or removed if needed so information is accurate and not cluttering the patient history.

Configure Fields for Precision

The Field Template Designer allows administrators to configure fields down to specific reference values and data ranges.

• Reference Values for Specific Fields: Set reference values, like lab test ranges, with color coded indicators to highlight out of range results for easy identification.
• Age and Value Ranges: Define age specific ranges for fields to help clinicians interpret results based on the patient’s age.
• Editable on Demand: Fields can be edited anytime, as clinical knowledge or practice evolves.

With these settings the system ensures information is entered as accurate as possible and error free during patient care.

Unique Value Fields for Core Information

Some fields, under “Unique Value Fields”, remain the same across multiple visits or forms. Examples are hereditary health conditions, nationality or allergies, so this data is stable and available throughout all encounters with the patient.

• Consistent Cross Visit Data: Fields like allergies, major diagnoses and chronic conditions remain the same across visits, makes patient management easier.
• Structured History Sections: Histories under Unique Value Fields (e.g. family and social histories) are great for tracking lifelong health data that informs care planning.

These stable fields provide a base of historical data for clinicians to build on as they monitor patient progress.

Form Customization

The Form Template Designer also allows for custom questionnaires, lab forms and consultation forms. Clinics can add only the data they need, no information overload or irrelevant questions.

• Questionnaires: Custom questionnaires to collect specific information during patient intake or follow up. Whether mental health or specific lifestyle factors, questionnaires can be designed to suit practice needs.
• Lab and Imaging Forms: Custom forms for lab results or imaging notes to document these results within the patient record, all diagnostic information in one place.
• Multiple Layouts for Consultations: Each consultation form can be designed to collect specific information, notes align with each clinician’s preference or practice specialty.

This flexibility brings consistency and customized documentation so the record keeping system matches the clinic’s practice.

Widgets and Visuals

Widgets on the patient chart dashboard allow users to highlight important information, like latest lab results or medication history, so key information is at their fingertips.

• Latest Values Widget: Displays recent values for designated fields, which can be chosen based on what the clinician considers most relevant for the patient’s current condition.
• Field Values Widget: A grid or chart format widget to visualize patient data, useful for tracking metrics like blood pressure over time.
• Drag-and-Drop Dashboard: Users can move and resize these widgets to build a custom view that suits their needs.

These widgets are quick reference points to save time searching for specific data during consultations.

Advanced Document Integration

Patient records aren’t just text fields. Our system also supports different document types, Word and PDF templates and direct uploads so all relevant paperwork can be stored and accessible in the patient’s profile.

• Word and PDF Template Support: Create templated documents like visit summaries or discharge instructions with data fields that merge from the patient record.
• Inline Editing: In-line document editing allows clinicians to update or fill in fields without opening additional software.
• Media Attachments: Images, X-rays and other media can be stored in the patient profile so all relevant documentation is in the medical record.

Document integration provides a full narrative of patient interactions, from consultation notes to diagnostic imaging, for complete record keeping.

Conclusion

Patient histories and medical records in our system are more than just a set of data points. This system’s flexibility, from custom fields and forms to layout and widgets, is a workspace where healthcare providers can document, visualize and recall a patient’s health journey. Whether you’re tracking family history, updating social history or reviewing a patient’s full timeline, it’s all about usability and accuracy.