Best Practice Guidelines: Medical | Dental | Allieds

General Examination Forms

The general examination forms are used to record observations made during a patient examination. Here we’ll discuss some of the general examination forms that can be used on a daily basis:

• General Examination
• Quick Note
• Triage Form (Triage/ER Practices)
• Different WCA Forms
• Covid Questionnaires 

General Examination (GPE)

This form is structured in such a way to help practitioners quickly and easily capture their observations. The values entered into this form will also become part of the patient’s clinical history which can be reviewed to see whether a patient’s health has improved/declined over a period of time. When abnormal measurements are entered it will be indicated in red on the form. This form includes the following sections:

Physical Examination

In the Physical Examination, the Practitioner will listen to the patients and capture all the information of the condition and complaints. 

Medical History

Medical History is a record of health information about a patient and his or her close relatives that should be recorded by the Medical Practitioner and will affect the way that the patient is diagnosed and treated. The Medical History in the Physical Examination will pull through the information from the Medical History captured on the patient file, for example, the:

• Allergies
• General History
• Vaccinations

For more information on the Medical History, please refer to the Medical History Sub Chapter in the Clinical Information section.

The Physical Examination is used to capture the following details:

• Complaint - What the patient says is the problem.
• Notes - Any notes the practitioner needs to remember about the patient condition and general examination.
• Images - Any images can be uploaded onto the general examination, for example, the patient has an injury and the practitioner needs to keep track of how the wound progress with the follow-up consultations. 
  
• Symptoms - The practitioner needs to capture all the symptoms the patient have or complain about.
• History - Allergies, General History (General Health and Family History) and Vaccinations the patient has or did receive in the past.
  
• Vital measurements - for example, blood pressure, pulse rate, temperature, BMI, waist/hip ratio or FRAMINGHAM score.
• Sideroom investigations - for example, urine test, glucose, cholesterol, HIV, malaria, HDL.
• JACCOLD - Jaundice, Anaemia, Clubbing and Spooning, Cyanosis, Oedema, Lymphadenopathy and Dehydration.

Review of Systems

In the Review of Systems section, you will find system visualisations, space to make notes about each sub-system and in some subsections, you will find quick capture features like yes/no questions that allow the practitioner to easily capture their findings. The practitioner can also make annotations on the system visualisations. The information in this section can assist the practitioner in planning the treatment of the patient. This section is split into the following sections (subsections under each section will be indicated by the information between the brackets):

ENT and Ophthalmology

The ENT and Ophthalmology section can be used to capture information about the patient's eyes, ears, nose, mouth, throat, facial views and general notes on the ENT and Opthalmology.

The ENT and Ophthalmology section should be completed when the practitioner examines the patient eyes, ears, nose, mouth, throat, head or neck.

Respiratory

The Respiratory section will be used to capture the patient condition on signs of distress, chest wall, patterns of breathing, palpation, percussion, auscultation.

The human respiratory system is a series of organs responsible for taking in oxygen and expelling carbon dioxide. The primary organs of the respiratory system are the lungs, which carry out this exchange of gases as we breathe.

Cardiovascular

The Cardiovascular section will be used to capture the patient conditions on the patient heart rate, heart sounds/murmurs, precordial palpation, JVP/neck veins, ECG and general notes on the cardiovascular system.

The cardiovascular system comprises the heart and blood vessels and carries nutrients and oxygen to the tissues of the body.

Abdominal

The Abdominal section will be used to capture the patient condition on the inspection, palpation, percussion, auscultation and general notes on the patient abdominal condition.

The abdomen includes a host of organs including the stomach, small intestine, colon, rectum, liver, spleen, pancreas, kidneys, appendix, gallbladder and bladder.

Musculoskeletal

The Musculoskeletal section will be used to capture the patient condition on the patient head, gait, arms, legs, spine and general notes of the musculoskeletal system.

A combination of the muscular and skeletal systems working together includes the bones, muscles, tendons and ligaments of the body.

Genito-urinary

The Genito-urinary section will be used to capture the condition of the patient on the patient breasts, cervix, inspection, palpation, percussion and general notes of the genito-urinary system.

The genito-urinary system or urogenital system is the organ system of the reproductive organs and the urinary system. 

Lymphatic

The Lymphatic section will be used to capture the patient condition on Inspection and general notes of the Lymphatic system.

The lymphatic system is part of the vascular system and is an important part of the immune system, comprising a large network of lymphatic vessels that carry a clear fluid called lymph directionally towards the heart.

Immunological/Endocrinology

The Immunological/Endocrinology section will be used to capture general notes of the patient condition.

The immune system is the body's defence against infectious organisms and other invaders and endocrinology is the collection of glands that produce hormones that regulate metabolism, growth and development, tissue function, sexual function, reproduction, sleep, and mood, among other things.

Dermatological

The Dermatological section will be used to capture general notes of the patient condition

Comprises the skin and its appendages acting to protect the body from various kinds of damage, such as loss of water or damages from outside. The integumentary system includes hair, scales, feathers, hooves, and nails.

Psychiatric

The Psychiatric section will be used to capture the patient condition on ADD, ADHD, anxiety, bipolar disorder, depression, OCD, substance dependency and general notes.

A psychological disability or psychiatric disability refers to a spectrum of mental disorders or conditions that influence our emotions, cognitions, and/or behaviours. 

Neurology

The Neurology section will be used to capture the patient condition on cranial, dermatomes, reflexes, sensory system, motor system and general notes.

The nervous system is made up of two parts: the central and peripheral nervous system and deals with disorders of the nervous system. It includes the brain, spinal cord and nerves.

Diagnosis & Plan

Diagnosis and Plan assist in planning the patient's treatment and recovery. Assisting in the following:

• Quick once-off diagnosis.
• Easy guided custom procedures.
• Single click invoicing and direct scripting.
• The treatment plan can be built and will assist in knowing what to expect and when important dates for follow-ups are necessary.

Quick Note

The quick note can be used to make short notes and add pictures when a practitioner does not want to use the General Examination form. It can also be used to capture any additional information about the patient examination. The quick note is a free text function, the practitioner can add any information into the section with special features, for example, to bold some of the text, or put in bullets to assist in better reading of the notes that were made.

Covid19 Questionnaire + Screening

• The questionnaire form is a research instrument consisting of a series of questions for the purpose of gathering information from patients regarding their Covid risk level. Questionnaires have advantages over some other types of surveys in that they are cheap, do not require as much effort from the questioner as verbal or telephone surveys, and often have standardised answers that make it simple to compile data. 
• The Practitioner will immediately have the response/results on the GoodX system after the Patient completed the Questionnaire that the practice sends to them via SMS or email. 
• The Patient will receive an SMS or email once they have booked a Telehealth appointment online, with a LINK that will redirect them to a pre-screening questionnaire that they should complete determining their risk.
• The COVID-19 pre-screening questionnaire will have a drop-down next to each question to complete your answer. Each question will have points allocated to it, this will determine the patient's risk of having the virus which will reflect on the Doctors Diary on the Patients appointment.

Triage Form - Nurses

• A Triage form is a clinical form that the ER nurses use to check the patient's vitals and appearance. 

• This form automatically changes the colour of importance regarding the information that the nurse completes to determine the risk the patient is at.

GoodX also has a Triage process that is connected to an EMR Form. Please refer to our Learning Centre for more information on the Triage and available courses on the Triage process.

WCA (Workers Compensation Act) and RMA (Rand Mutual Assurance) for IOD (Injury on Duty) Forms