Description

Section used for the search of screens for the clinical evaluation of the patient. 


Access


Through Main Menu

  • In the main menu, press the “Clinical” button. 
  • Choose the patient from any section of the screen. 
  • Once selected, press the “Search” button, located at the top left of the “Advanced Progress Note” screen. 


Sections

  • Search: Allows you to search for the screens.
    • ABG: Display the screen to record the patient's blood gas analysis information.
    • Active Tasks: Displays the patient's pending clinical tasks screen. 
    • Add Allergies: Display the screen to record the patient's allergies.
    • Add Immunization: Display the screen to record the vaccines administered to the patient. 
    • Add Order:Display the screen to add orders to the patient.
    • Add Order Result: Display the screen to record the patient's order results.
    • Add Problem List: Displays the “Select Code” screen, to record the patient's active diagnoses.
    • Add Referral: Display the screen to add patient referrals.
    • Add Result Template: Display the screen to print the “Templates” of the order results.
    • Add Vital Sign: Display the small screen, to record the patient's vitals. 
    • Addendum / Amendments: Display the screen to record “Addendum” notes to the patient's note.
    • Alerts: Displays the patient's clinical alerts screen.  
    • Anticipatory Guidance: Display the screen to record preventive care information for the pediatric patient. 
    • Blood Sugar: Display the screen to record the patient's blood sugar levels. 
    • Calls: Display the screen to record the calls made by the patient.
    • CCD: Displays the “Patient Summary” screen.  
    • Chief Complaint: Displays screen, to record the patient's symptoms and main complaint. 

    • Clinical Report: Summary:  Displays the screen, which allows you to create reports on the patient's clinical information. 

    • Clinical Support: Display the screen, to search for educational information on any topic for the purpose of being sent to the patient portal. 

    • Clinical Tasks: Display the screen to record the clinical treatment of the patient. This screen works in conjunction with the “Workflow” screen. 

    • Custom Alerts: Display the screen to configure the clinical alerts for the selected patient. 

    • Custom Evaluation: Display the screen to configure the clinical alerts for the selected patient. 

    • Delivery History: Display the screen to record the patient's previous pregnancies and miscarriages. 

    • Development MileStones: Display the screen to record the pediatric patient's developmental information. 
    • Documents: Display the screen to register the patient's clinical documents. 
    • Drug Prescription: Displays screen to create prescriptions. 
    • Education: Display the screen to record and deliver educational information to the patient. 
    • Evaluation Forms: Display the screen to record and save the patient's questionnaires. 
    • Evaluation Notes:  Display the screen to record specific notes about the patient's evaluations. 
    • Export Progress Notes: Displays the screen that allows you to select, print and save the selected progress notes in “PDF” format.
    • External Imaging: 
    • Family History: Display screen, to record the patient's family history. 
    • Immunizations: Display the screen to record the patient's vaccines administered. 
    • Implantable Devices: Display the screen for adding or editing on medical devices.
    • IV Manager: Display the screen to record the sera administered to the patient as part of the treatment.  
    • Main Allergies: Display the main allergy screen. 
    • Main Orders: Displays the main order screen.  
    • Medication History: Display the screen to record the patient's active medications. 
    • Menstrual History: Display the screen to record the patient's menstrual history. 
    • Optimal Instrument: Displays the screen, where the instrument was transferred that measures the difficulty through 22 options, that a patient needs, to carry out various functional activities. 
    • Order Set: Displays the order group screen already configured for a specific diagnosis. 
    • Past History: Displays the screen to register documents related to the patient's clinical history through templates. 
    • Patient Notes: Display the screen to record documents related to the patient's medical history through templates.
    • Patient Summary: Displays the screen with the summary of the patient's clinical information. 
    • Pediatric Charts: Display the screen showing the different growth charts of a pediatric patient.
      Physical Exam: Display the screen to record information about the physical examination performed on the patient. 
    • Physical Examination: Display the screen to record injury and/or trauma, at the physical level of the patient.
    • Physical Therapy: Display the screen to record and save the patient's physical therapy information.
    • Care Plan: Display the screen to record the patient's care plan. They will contain the Snomed code, so that they can be included in the CCDA. 
    • Pregnancy: Display the screen to record the patient's current pregnancy information and prenatal visits.
    • Procedures: Display the screen to record the procedures performed on the patient. 
    • Procedures Imaging: 
      R.O.S. (Review of Systems): Display the screen to record the information for the review of the patient's systems. 
    • Rule Outs: Display the screen to configure and select all exclusions for a diagnosis or patient condition. 
    • Signatures: Display the screen showing all the users who have intervened and saved information in the clinical evaluation of the patient. 
    • Sleepiness Scale: Display the screen to record the patient's sleep scale information. 
    • Smoking Status: Display information, to record information about the patient's smoking status.
    • Tasks History: Display the screen where the history of the clinical tasks assigned to the patient can be viewed.
    • Triage: Display the screen to record information about the patient's symptoms for which he/she came to the center or office. Usually, this information is recorded by the nurse. 
    • View Orders: Display the screen where the patient's orders, referrals and prescriptions can be viewed and printed. 
    • Vital Signs Main: Displays the main screen for recording the patient's vital signs. 
  • Close: Closes the section.


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