Best Practice Guidelines: Healthcare Practice Management
7. Clinical information
7.5. Treatment Plan
A treatment plan contains details about the patient’s condition as well as the practitioner’s recommended treatment. Following will be an explanation of some of the clinical forms that the practitioner can use to assist them with treatment the patient:
For certain procedures or treatments, the patient will need an authorisation from their medical aid to proceed with the treatment or procedure.
The authorisation number received from the patient medical aid will be an indicator that the medical aid will pay for the procedure or treatment that they’ve agreed on.
When the Authorisation number has been received the authorisation can be set up on the patient electronic file to pull through to the billing and go through to the medical aid when the invoice is switched.
The authorisation number must be included on the billing to ensure payment from the medical aid.
Scripts will allow the patient to get the necessary medication to aid in his/her treatment from any pharmacy. The script form has a lot of features that make scripting a quick and easy process, the practitioner can decide which features suit their workflow. Following will be an explanation of some of these features:
The most basic script that can be created is an acute script. An acute script consists of a list short term medications with directions of use and a diagnosis.
Every script line has a directions builder which assists the practitioner in creating directions of use for each script item. The directions builder allows the practitioner to populate the directions field by selecting options from some dropdowns (e.g. time of day, meal relationship and route) and entering numbers in some fields (e.g. dosage, frequency and days supplied).
Chronic scripts are scripts that contain chronic items. An item can be marked as chronic by either manually marking the item as chronic or by marking the item as more than five times repeatable. When a script as a whole is marked as more than five times repeatable all of the script items will be marked as chronic.
The practitioner can quickly recreate any formerly scripted script line or script from the patient’s script history which is displayed at the bottom of the script.
Script favourites and macros
When creating a script the practitioner can save a script item with its directions of use as a favourite or save a couple of script items as a macro. When creating a script the practitioner can easily add script items by adding favourites/macros to the script.
Import chronic lines
Another way to quickly create script lines is to import script lines from the medical history where you can setup a script per chronic condition for each patient.
On every script line the practitioner can quickly view generics for the selected script item and easily replace the script item with a generic.
Practitioners can easily view the MIMS info for a selected script item.
Drug interaction checker (DIC)
While a script is being created the drug interaction checker checks for interactions between all of the scripted items and warns the practitioner about interactions. The practitioner can also open the DIC on the script to see more information about the interactions as well as to see information about the side effects of the medication and the directions of use for each medication.Consumables
Consumables can be included into the script.
The practitioner can sign the script electronically or import their signature from the settings on to the script by using the pin that they set up in the settings along with the signature.
Add script lines to invoice
When the practitioner is done with the script they can add the script lines to the invoice.
Medical Certificate (Sick Note)
Sick notes are used to indicate that the patient has a certain condition and also as a declaration that the patient is unfit to continue with their normal daily routine or responsibilities for a specified period of time. The sick note can be completed and signed electronically by the medical practitioner. At the top of the sick note form a record of the patient’s previous sick notes is displayed as well as the patient’s details. The following functions on the sick note will assist in creating the sick note with all the necessary information:
- Patient details will be filled in from the booking that was made
- Previous sick notes will be displayed
- ICD10 can be chosen from a list
- Diagnosis can be set to display on the printout
- The diagnosis that will be displayed on the printout can be modified
- Date of treatment (by default set to appointment date) can be set
- The absent from date will default to the appointment date and can be modified
- Number of days absent field
- Absent to and including date field. This field can manually be set or automatically updated by changing the number of days absent field
- A follow-up date can also be set
- Light duty from date field
- Light duty to date field
The practitioner can select one of the following statements to be added to the sick note that states that the information contained in the sick note is:
- According to their opinion/knowledge or according to what they were informed by the patient, if the last option is chosen the patient’s signature can be captured
- The activities/responsibilities that the patient is unfit for can be selected from the following list: work, school, sport, university/college, travel
The practitioner can also create a family responsibility certificate for a family member.
The practitioner can sign the sick note electronically or import their signature from the settings on to the sick note by using the pin that they set up in the settings along with the signature
All the completed information will be compiled into a short story on the printed sick note with all the information that was added to the sick note
A referral letter is a form that can be completed when the patient has to be referred to another medical practitioner for additional or special treatment that the current practitioner cannot perform. The referral letter contains the following features:
- Date of referral (default date is the appointment date)
- Referring note (free text field)
- Patient at practice since (when did the current treatment start)
- Doctor signature
- Diagnosis details (chronic, previous and reason for referral)
- Specialist details (name, practice number, address)
- Appointment details (date, time and location details)
The prescription letter will be used to prescribe medication for a patient. The patient can take this script to the pharmacy to get their medication.
Signata is also called prescription codes.
The signata can be set up with a shortcut and the description. GoodX has a default list that can be used.
Example: When "1B14" is typed in the following will display in the signata column: TAKE ONE IN THE MORNING AND ONE AT 14:00.
This is a preset list of directions of use.
Medication can be prescribed on the system, so there is no need to purchase prescription pads. All the medication is also loaded onto the system via MedPrax. The signata is also loaded by GoodX and may be maintained by the user