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Clinical

Visits (EMR)

The electronic medical record. A visit (encounter) is one contact — outpatient, emergency or inpatient — with vitals, complaint, history, examination, diagnoses coded in ICD-10, orders, prescriptions, referrals and a signed note. The patient’s whole history is one click away from the visit.

For:PhysiciansNursesMedical records

Where:Clinical › Visits · All Visits · Vital Signs

The visit: vitals with NEWS2, diagnoses, orders and the note, with the history in the side panel.
The visit: vitals with NEWS2, diagnoses, orders and the note, with the history in the side panel.
Today’s visits per practitioner and department.
Today’s visits per practitioner and department.

Before you start

Note templates
Clinical › Configuration › Note Templates: SOAP templates per specialty that pre-fill the note.
Specialty forms
Structured forms per specialty — see the Specialty Forms chapter.

How to

Start a visit from the queue

  1. Appointments › Today’s Queue › Start consultation on the arrived patient (or on the appointment itself).
  2. The visit opens in state In progress with the patient’s allergies, chronic conditions, last visits and open results in the side panel.
  3. A walk-in without an appointment: Clinical › Visits › New, choose the patient and the department.

Record vital signs

  1. On the visit, Vital Signs › Add: respiratory rate, saturation, oxygen, blood pressure, pulse, temperature, consciousness, weight, height.
  2. NEWS2 is computed the moment all seven parameters are in; an incomplete set shows “not scored” with what is missing.
  3. A medium or high score shows the response the score calls for; on an admitted patient it also raises an activity for the ward nurse.

Document the consultation

  1. Chief complaint, history, examination; pick a note template if one fits.
  2. Add diagnoses from the ICD-10 catalogue; mark one as principal.
  3. Orders tab: laboratory tests, imaging, procedures and nursing orders — each becomes a request in that department’s queue.
  4. Prescription: see the Prescriptions chapter.
  5. Follow-up date and instructions print on the visit summary the patient takes home.

Refer to another practitioner or department

  1. Clinical › Referrals › New from the visit: target department or practitioner, urgency, the reason.
  2. The receiving department sees it under its Referrals; accepting it books the appointment.

Close and sign the visit

  1. Click Done. The visit is signed with your name and time and can no longer be edited; an addendum goes in the chatter.
  2. The charges captured during the visit are on the patient’s bill at the cashier.
  3. Undo is available to a clinical manager only, and is logged.

Read a patient’s history

  1. From any visit, the side panel lists previous visits, admissions, results and prescriptions; click any of them.
  2. The patient form › smart buttons open every part of the record: Visits, Results, Prescriptions, Admissions, Bills, Documents.

Questions the desk asks

A flag appeared on the visit — what is it?

A clinical rule found a measurement past a threshold. It names the measurement; it never diagnoses or blocks care. See Specialty Forms & Clinical Flags.

See also: Specialty Forms & Clinical Flags Prescriptions & Orders Certificates & Consents Appointments, Queue & Teleconsultation

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