Best Practice Guidelines: Healthcare Practice Management

7. Clinical information

7.1. Medical History

The medical history will normally be completed at the first visit for each patient and updated at each subsequent consultation. This will allow the medical practitioner to effectively treat and manage their patient’s health.

When a patient’s medical history has been completed in GoodX the practitioner will be warned when potentially harmful actions are taken when treating the patient such as prescribing medication that the patient is allergic to.

Completing the medical history also streamlines the practitioner’s workflow e.g. chronic scripts can be setup for a patient and then every time the patient needs a repeat chronic script, the practitioner can easily recreate the script.


Web App: Medical History

In the Web App the medical history comprises the following information:

General History

General Health

In this section some of the patient’s habits (e.g. How often they smoke, drink alcohol, exercise and use recreational drugs) can be captured and their general well being can then be assessed. This information is also displayed in the medical history summary which is visible from all screens of a patient booking.

Family History

Here the practitioner can record the patient’s family medical history i.e. what chronic conditions and major medical events have family members experienced. For example Cancer, Hypertension, Asthma, Strokes etc. Practitioners can use this information to help patients manage their health risks by suggesting that patients take certain actions. Knowing a patient’s family medical history can help practitioners with early diagnosis of serious conditions that the patient may be at risk of developing by checking for signs of the conditions on a regular basis.


Chronic

This section is used to keep track of the patient’s chronic conditions and when the patient was diagnosed with each condition. A script template (i.e. medications, directions for use, dosages etc.) can be created for each chronic condition that the patient is diagnosed with so that the practitioner can quickly and easily recreate a chronic script for the patient. This information is also displayed in the medical history summary which is visible from all screens of a patient booking.


Allergies 

A patient’s allergies can be recorded here. A warning message will be displayed whenever the practitioner creates a script/invoice containing an item which the patient is allergic to. This information is also displayed in the medical history summary which is visible from all screens of a patient booking. The Allergies section consists of the following features:

No Allergies

If a patient has no allergies it can be noted on their medical record.

Message

A message can be added to a patient’s medical history which will be displayed in the medical history summary which is visible from all screens of a patient booking. This message can also be marked as important which means it will be displayed in a popup message whenever any of the booking screens are opened for that patient. For example, a message could be setup to remind the practitioner of the patient’s severe reaction to a certain allergen.

Allergens

The allergens are divided into three categories. In each of the categories the patient’s allergies can be recorded by the type of allergy and a message can be added to each recorded allergen. The allergens are divided into the following three categories:

  1. Drug Classes: Here you will find a list of drug classes that a patient could potentially have a severe immune response to. A drug class is a set of medications and other compounds that have similar chemical structures, the same mechanism of action (i.e. bind to the same biological target), a related mode of action, and/or are used to treat the same disease.
  2. Natural Allergies: This list contains natural allergens such as eggs, nuts or dust. Natural allergens are products that contain any substance produced by life.
  3. Chemical Allergies: This list contains chemicals that can cause an allergic response. In this section the practitioner can search for chemical allergens by medication i.e. the patient knows they are allergic to Panado thus the practitioner can search for Panado in the Search by medicine field and the system will show a list of all the chemical allergens contained in Panado e.g. paracetamol.


Treatment History

This section contains a list of treatments that the patient has had. The following information can be recorded per treatment:

  1. Treatment description
  2. Start date
  3. End date
  4. Place of treatment
  5. Dr notes - such as observations during the treatment


Operation History

This section contains a list of operations that the patient has had. The following information can be recorded per operation:

  1. Operation description
  2. Operation date
  3. Doctor/Surgeon
  4. Hospital
  5. Notes - such as complications during surgery


Gynaecological History

Past Pregnancies

This section contains a summary of the patient’s past pregnancies as well as a list with the details of each past pregnancy. The details of each pregnancy that can be captured are: date, GA weeks, length of labour, birth weight, sex, anesthesia, place of delivery, delivery type, ectopic, multiple births, c-section, comments/complications. The summary contains the following information: total (full term/preterm) pregnancies, total living, total spontaneous abortions, total inducted abortions, total ectopics, total multiple births, total c-sections.

Menstrual History

Here information about the last menstrual cycle is captured such as the duration, start date and end date.

Genetics Screening/Teratology Counselling

This section contains information about the patient and their family, for example, mental retardation, recurring stillbirths, or down syndrome.

Infection History

If the patient has been infected with or exposed to certain infections (e.g. HIV, TB or Syphilis) it can be recorded in this section.


Occupational and Demographic History

The patient’s occupation also plays a role in their health and thus it is important to know where the patient works and what the patient does for a living. In this section the patient’s occupation can be captured as well as any additional notes about the patient’s occupational and demographical history.


Desktop App: Clinical Info/Medical history

In the desktop app the clinical info/medical history consists of the following sections:

Allergies

Allergies are linked to all medications, billing and scripting. This feature will display important messages and warning messages when a patient’s allergies are triggered.

When a patient’s allergies are deleted from the clinical info tab, they are recorded on the deleted allergies tab. This feature is useful when an allergy has accidentally been removed or if a patient no longer has an allergy but it is still relevant to the patient’s medical care.

The allergens are divided into two categories. In each of the categories the patient’s allergies can be recorded by the type of allergy and a note can be added to each recorded allergen. The allergens are divided into the following two categories:

Active Ingredients & Drug Classes

Here you will find a list of drug classes and active ingredients that a patient could potentially have a severe immune response to. A drug class is a set of medications and other compounds that have similar chemical structures, the same mechanism of action (i.e. bind to the same biological target), a related mode of action, and/or are used to treat the same disease. In this section the practitioner can also search for active ingredients by medication i.e. the patient knows they are allergic to Panado thus the practitioner can search for Panado in the Search by medicine field and the system will show a list of all the active ingredients contained in Panado e.g. paracetamol.

Natural Substances

This list contains natural allergens such as eggs, nuts or dust. The practitioner can also add natural allergens to the list. Natural allergens are products that contain any substance produced by life.


Chronic Conditions & Chronic Medicines

A patient’s chronic conditions and medications can be documented under this section.

Chronic Conditions can be chosen from an ICD10 list (PMBs will be indicated), the date that the chronic condition was captured will also be recorded. The practitioner can also add a note about any important information pertaining to the patient’s chronic condition. If the patient’s chronic condition is registered at a specific medical aid they will have an authorisation code for any treatment that they receive pertaining to that chronic condition, the practitioner can add this as a note to the patient’s chronic condition record.

Chronic Medication can be chosen from a medication list and a note can be added to each medication with the directions of use.