Best Practice Guidelines: Healthcare Practice Management & POPIA Compliance Framework

Best Practice Guidelines: Healthcare Practice Management

POPIA Compliance Framework




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9. Clinical Information: Roles, Purpose & Process Diagram

9.2. General Examination Forms

The general examination forms are used to record observations made during a patient examination. Here we’ll discuss two types of general examination forms:

  1. General Examination
  2. Quick Note


General Examination

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

This section is used to capture the following details:

  1. Complaint
  2. Notes
  3. Images
  4. Symptoms
  5. History - Allergies, General History (General Health and Family History) and Vaccinations
  6. Vital measurements (e.g. blood pressure, pulse rate, temperature, BMI, waist/hip ratio, FRAMINGHAM score, etc.)
  7. Sideroom investigations (e.g. urine test, glucose, cholesterol, HIV, malaria, HDL)
  8. JACCOLD (Jaundice, Anaemia, Clubbing and Spooning, Cyanosis, Oedema, Lymphadenopathy and Dehydration)


Review of Systems

In this 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

Eyes, ears, nose, mouth, throat, facial views and general notes.

This section can be used to review the ear, nose, throat, head and neck systems.

Respiratory

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

Heart rate, heart sounds/murmurs, precordial palpation, JVP/neck veins, ECG and general notes.

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

Abdominal

Inspection, palpation, percussion, auscultation and general notes.

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

Musculoskeletal

Head, gait, arms, legs, spine and general notes.

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

Genito-urinary

Breasts, cervix, inspection, palpation, percussion and general notes.

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

Lymphatic

Inspection and general notes.

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

General notes.

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

General notes.

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

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

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:

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


Advanced Features

Here are some advance features that can assist the practitioner in capturing important information correctly and easily. These features are applicable to each section:

  1. Add images to any section of the form
  2. Use your phone as a clinical camera
  3. Make annotations on any image
  4. Download, email or print the form


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.

Use a phone as a Clinical Camera 

  • When the practitioner needs to take a photo of an injury or wound, the practitioners personal cellphone can be used to take the photo and be uploaded immediately onto the patient electronic file under the clinical information. 
  • The function will delete the original photo from the practitioner’s personal phone while uploading the photo to the patient’s file. 
  • This will assist in keeping the patient privacy.
  • Notes and drawings can be made on the photo and be saved. 
  • The photos can be used to indicate the process of the wound or injury.  

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 standardized 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 telemed appointment online, with a LINK that will redirect them to a pre-screening questionnaire that they must 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.


WCA Forms - Workers Compensation for IOD (Injury on Duty)

  • Workers compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee's right to sue his or her employer for the tort of negligence. There are four distinct types of Workers compensation benefits:
    • Medical treatment benefits.
    • Disability benefits.
    • Supplemental job displacement benefits.
    • Death benefits.
  • In GoodX there are multiple WCA Forms available for the Practitioner to complete:
    • WCA Disease First report: The purpose of the Disease first report is for the Practitioner to capture and provide full details on the IOD for the patient and the symptoms the patients are experiencing.
    • WCA Disease Progress or Final Report: The purpose of the Disease progress or final Form is for the Practitioner to capture and provide the progress of the Patient after the first report was done.
    • WCA Exposure History: The purpose of the Exposure History Form is for the Practitioner to capture and provide information regarding the environment in which the employee has been exposed to His/Her disease.
    • WCA Final: The purpose of the WCA final report is for the Practitioner to capture and provide full details on the progress and end results for the patient. The final report will be done after the patient was treated and what the final outcome for the injuries sustained is. 
    • WCA First Report: The purpose of the WCA first report is for the Practitioner to capture and provide full details on the IOD for the patient. When the injury/accident took place etc.
    • WCA Follow Up: The purpose of the WCA follow up report is for the Practitioner to capture and provide full details after the patient was treated and if the patient should come for a follow-up and what the follow-up appointment will include.