Clinical Information (Web App)

 

Medical History 

• Medical history is a record of health information about a person 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. This tab will be found in the Clinical Case when a patient is treated. 
  

General History

• General Health 
  

The following general Health details about the Patient can be captured in the General History Tab:

• Smoking (per day)
  
• Alcohol (per week)
  
• Exercise (per week)
  
• Recreational Drugs
  

New Function - A general notes section was added on General History:

• Select a debtor >> On the sidebar select Clinical History >> Medical History >> General History >> general notes section was added for free text.

Add additional message block with pop-up under General History:

• Under General History add an important message box. This box will be used for general notes which the Dr would like to be prompted with. This message should concatenate with the allergies pop-up with a clear indication which message relates to which section.
• Select a debtor >> On the sidebar select Clinical History >> Medical History >> General History >> Important Message.
  

• This message will be displayed when opening the Billing screen.
• Go to a debtor >> On the sidebar select Invoice >> Patient warning message will display the important message that was typed under the General Health section.

Family History

• The Patient's Family History can be ticked and specified in this section.
  

Chronic

• The Patient's chronic conditions and the script items for these conditions are captured under the Chronic section. 

• Search for the Chronic Diagnosis: The chronic diagnosis is searched under this option and will be added to the patient's profile once selected. 
• Please see an example above of the chronic diagnosis, "Asthma" that is already added for this patient. 
• Chronic Script Items
• Script Items for the patient's chronic condition can be added under this section as per the example below:

• Date: This is the date that the patient was diagnosed with the condition
• Medication: Choose the medication that you regularly prescribe for the patient's condition.  
• Dosage: The amount of a medicine or drug that the patient takes or should take.
• Route: The path by which a drug or substance is taken into the body.
• Frequency: The number of times the medication should be taken daily.
• Days Supplied: The number of days that the drug should be taken.
• Total Quantity: The total quantity of medicine that should be dispensed. 
• Time of Day: This is the time of day that the medicine should be taken. 
• Meal Relationship: Should the medication be taken before meals, after meals, on an empty stomach, etc. 
• Repeat: Should the item be repeated. 
• Directions: The directions for how the drug should be taken 
• Add Script Item: Will add a new line to the script 

Allergies

• The Patient's allergies should be saved under this section and will affect scripting as a warning will display should you, for example, prescribe Amoxicillin to a patient that is allergic to penicillin.
  

• Warning Message: This is a text box for the treating practitioner to capture an important warning message specific to the patient, for example, if the patient is very allergic to something or if the patient behaves in a certain way, this is a free text box and the practitioner chooses the message that will display. 
  
• Important: If this checkbox is ticket the message will pop-up whenever the Invoice/Clinical screen is opened.
  
• Drug Classes: Choose the drug class that the patient is allergic to from the drop-down list, a note can also be added to the allergy. 
• Natural Allergies: Choose the natural substance that the patient is allergic to from the drop-down list, a note can also be added to the allergy.
• Chemical Allergies: Choose the natural substance that the patient is allergic to from the drop-down list, a note can also be added to the allergy. 

Allergies, Chronic Diseases and Important Messages saved will display on the top right corner of the Clinical/Invoice Screen once the conditions have been saved. 

Vaccinations and Travel History

Select a debtor >> On the sidebar select Clinical History >> Medical History >> Travel History >> + Add Vaccination / Add Travel History Item.

• Vaccinations are the administration of a vaccine to help the immune system develop protection from diseases. Doctors can now complete all the Vaccines the patient got, be it a child or adult in the medical history fields.
  
• Proof of vaccinations for travelling purposes will be available to complete under Medical History, for example. YELLOW FEVER vaccine may be required to cross certain international borders. A stamped vaccine certificate will be issued to you when you get the vaccine. The yellow fever vaccine can only be given by a registered provider. 
  

• Click on Save when done, or Cancel to Close without Saving.

TAKE NOTE: When the Medical History is completed, all the allergies and medical and family history that was completed will display in the top right corner. No info will be displayed if not filled in.

TAKE NOTE: to add more information to the medical history summary that is available in the top left corner of the clinical or invoice screen. Add a setting on User Entity Settings to enable the medical history summary to drop down automatically when entering the clinical or invoice screen.

• Settings >> User Entity Settings >> General Settings >> Medical History Summary >> Enable medical history summary auto dropdown on clinical screen