Best Practice Guidelines: Healthcare Practice Management & POPIA Compliance Framework

Best Practice Guidelines: Healthcare Practice Management

POPIA Compliance Framework




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8. Clinical Information: Roles & Purpose

8.4. Special Investigation Forms

Special Investigation forms are used for further examination, tests and investigations. Most of the forms will be used by specialist practitioners. Please also refer to the Clinical Information: Roles, Purpose and Process Diagram Section for more futures available in the clinical forms that can assist in the process. 

Some of the forms are:


Custom Forms

Custom forms allow the user to build their own forms according to the practice’s needs. The form can be compiled with specific questions and pictures or quick notes and free text fields.

The Custom Forms template setup allows a user to create forms with custom questions that are tailored specifically to the preference of the practitioner's needs. It is possible to add several different types of questions using drop-down menus, checkboxes, radio buttons etc. The practitioner is also able to add scoring to each question that allows them to make conclusions based on the answers received.

The custom form can be set up in 2 parts, one for the patient to be completed and a part that the medical practitioner can complete.

The practitioner can review the patient part and then complete the practitioner part.

The form can be built with the following type of questions:

  1. Short text
  2. Paragraph
  3. Linear slider
  4. Whole number
  5. Decimal number
  6. Date or/and Time
  7. Checkbox
  8. File upload
  9. Image upload
  10. Dropdown
  11. Checked dropdown
  12. Radio buttons
  13. Checkboxes
  14. Signature

Scoring can be enabled on questions that will allow an answer to be allocated a score or number.


Pathology Request

Pathology is the study of the causes and effects of diseases or injuries. The Pathology Request will allow the Doctor to send a Pathology Request electronically to one of the Pathologists to have a certain problem/disease tested and to get the blood works/test results back electronically on the system.

The following pathology integrations are available:

  • Skylims
  • Prelink
  • Lancet
  • Ampath
  • Vermaak & partners
  • Pathcare

The system allows the practice to send pathology requests to Ampath, Vermaak & Vennote, Lancet and Pathcare. The medical practitioner can select the tests that they want to be done on the patient, send the request electronically on the system to the specific pathologist practice of their choice.

The tests will be done at the branch of the patient's choice. When the tests are done the pathologist will upload the result on the system and a task will be created in the GoodX system for the practitioner to look at the results.

The tasks will be marked with red if the results contain abnormal results for some of the tests and thus require the practitioner’s urgent attention. This assists the practitioner with shorter waiting periods for results and also prevents results from getting misplaced.


Radiology Form

The Radiology Form will be completed by Radiologists before, during and after the Patient has X-Rays taken for a specific injury where they need to have a Sonar or X-Rays done. The Radiologist will use the Form to add the diagnosis, upload images, upload the *pdf Report and add the Procedure codes to the billing screen after the X-Rays were taken.

The following radiology integrations are available:

  • TecMed Africa
  • Millensys/Sectra
  • Alkeris & Alkepacs
Please see the example flow diagram of the integration between GoodX and Radiologist Systems:


Radiology forms can be completed by the Practitioner and taken with the patient to the radiologist. The Practitioner can print out the form or send it electronically via the system to the patient.

The Radiology form will automatically pull through the patient's personal details. The practitioner can add the diagnosis and ICD10 codes, patients clinical history, images of the injury or even attach a *PDF document to the Radiology Request. This will help the radiologist to know exactly what area to work on. 

When Creating a new Radiology booking on the Diary the Radiology Booking Type must be selected to indicate the Patient is booked for a Radiology Procedure. Selecting the Radiology Booking Type is important as a specific billing Code related to the Radiology booking Type is linked to the Radiology Booking. 

When the Radiology Booking Type is selected, a Radiology billing Code will automatically be added to the Invoice screen.


Eye Evaluation Form

The purpose of the Eye Evaluation Form is to document a series of tests performed by an ophthalmologist (medical doctor), optometrist, or orthoptist, optician, assessing vision and ability to focus on and discern objects, as well as other tests and examinations pertaining to the eyes. The Practitioner can print out the form or send it electronically via the system to the patient when completed after the evaluation.

The Doctor can make notes and add images under Management and tick if the Patients need Surgery, Alternative treatment or if there are any Risks and Complications about the Patient diagnosis.

The practitioner can add the diagnosis and ICD10 codes and images of the eyes to the Eye Eval Form. 

The Doctor can add the consultation and any other procedure codes that were done in the Appointment to the eye eval form and click on the 'Add to Invoice' button to generate the Invoice from the form.


X-Ray Integration

The X-ray integration on GoodX Web and Desktop allows you to quickly interact with your x-ray program and take an x-ray for any patient.
The end-user does not have to capture the patient file twice on both GoodX Web and your current x-ray program as the integration does it for you. 

The following x-ray integrations are available in GoodX: 

  • Kodak (Carestream)
  • VixWin
  • Easy Dental (Desktop App)
  • Sirona (Web App)


Physio Assessment

The main purpose of the Physio Assessment and re-assessment is critical in determining the correct physiotherapy treatment. They also determine whether a client requires a further medical evaluation from a physician (for example, for a non-musculoskeletal problem or for a musculoskeletal problem that requires immediate medical attention). Accurate and complete assessments ensure systematic documentation of a patient's medical history, diagnosis, treatment and care.


Dispense Form

A Dispense Form is a form that a Practitioner will use to dispense medication to a patient and allows the pharmacist or responsible person to dispense the items to the patient from within the practice instead of issuing a prescription that the patient will have filled at an external pharmacy.

When a practice is registered as a dispensing practice with a dispensing license as obtained by and accredited with the South African Pharmacy Council, the practitioner is able to supply medication to a patient directly from the practice.


Gastroscopy and Colonoscopy Forms

Gastroscopy

The purpose of the Gastroscopy Form is for the Doctor to document all findings during or after the procedure. A gastroscopy (examination of the stomach) can help confirm or rule out the presence of medical conditions like gastritis or peptic ulcers. In this procedure, an instrument called a gastroscope is used to look at the inside of the food pipe, the stomach, and part of the duodenum (the first part of the intestine).

Colonoscopy

The purpose of the Colonoscopy Form is for the Doctor to document all findings during or after the procedure. During a colonoscopy, your doctor uses a thin, flexible camera to check for abnormalities or disease in your lower intestine or colon. The colon is the lowest portion of the gastrointestinal tract that takes in food, absorbs nutrients, and disposes of waste.

The Gastroscopy and Colonoscopy Form is divided into the following sections:

  • Patient Information: The Patient Information section is used to collect demographic information as well as additional information about the patient.
  • Diagnosis: The medical diagnosis is the part where determining which disease or condition explains a person's symptoms and signs. It is most often referred to as diagnosis with the medical context being implicit.
  • Endoscopic Findings: After an examination of the inside of the body by using a lighted, flexible instrument called an endoscope the Doctor will document what he/she found during the procedure. In general, an endoscope is introduced into the body through a natural opening such as the mouth or anus.
  • Endoscopic Intervention: Endoscopic intervention is a useful alternative to operation in the treatment of upper gastrointestinal haemorrhage. This is a free text field.
  • Recommendations: If the Doctor wants to recommend the Patient to see another Practitioner or come back for a follow-up or any instructions for the Patients, it can be completed here. This is a free text field.


Gynaecologist Form

The purpose of the Gynaecology Form is for the Gynaecologist to document all findings during or after the procedure. During a gynaecology appointment, your doctor will perform a vaginal and cervical exam with a speculum, which is a device they'll insert into your vagina and expand to get a better view of your vaginal walls and cervix. An assessment of your current health status. A breast exam to check for lumps, skin changes, or nipple discharge. A pelvic exam to check your vulva, vagina, cervix, uterus, rectum, and pelvis, including your ovaries, for masses, growths or other abnormalities.

The Gynaecologist Form is divided into the following sections:

  • Examination: For the examination, the doctor inspects the external genital area and notes the distribution of hair and any abnormalities, discolouration, discharge, or inflammation. This examination may detect no abnormalities or may give clues to hormonal problems, cancer, infections, injury, or general health.
  • Breasts: Examination of the breasts is a screening method used in an attempt to detect early breast cancer. The method involves the Doctor looking at and feeling each breast for possible lumps, distortions or swelling. 
  • Cervix: A pelvic exam is a doctor's visual and physical examination of a woman's reproductive organs. During the exam, the doctor inspects the vagina, cervix, fallopian tubes, vulva, ovaries, and uterus.
  • Perineum: Examination of the female perineum consists of an evaluation of the constituent musculoaponeurotic and sphincteric structures and a global assessment of any abnormalities of pelvic and perineal tone.