Clinical Information (Web App)

The Outcome section of the General Examination form is completed once the visit with the Patient has been concluded. If anything of significance has occurred, such as whether a sick note or script has been issued, the Practitioner is able to make note of these changes. Larger outcomes can also be made note of, such as whether the Patient requires a transfer of facilities, as well as the name of the future treating Specialist. 

• The contents of the user manual will consist of the following information:
• Treatment Completed
• Script
• Sick Note
• Admit/Transfer
• Specialists

• This user manual will start on the General Examination form, Diagnosis and Plan panel.  

• For more information regarding the General Examination form, please refer to the user manual: General Examination Overview.

• Click on the Diagnosis and Plan panel.

• The Diagnosis and Plan panel will expand.

• Navigate to the Outcome segment of the panel.

Treatment Completed

• Tick the Request Follow-Up Visit checkbox if the Patient is going to need a follow-up visit with the Practitioner.

• Once Ticked, a Follow-Up Date field will appear. 

• Clicking on the Follow-Up Date field will open up a date picker.

• Click on the desired date to select it. 

Script

• Tick the Script Completed checkbox if the Patient has received a prescription medication note.

Sick Note

• Tick the Sick Note Completed checkbox if the Patient requires a sick note from the Practitioner.

• Once Ticked, a TTO (To Take Out) field will appear.

• Click on the Select a TTO Type drop-down menu for additional options.

• MEDS: To take out medication after the consultation, the Medication might have an influence on their working capabilities. 
• MATS: To take out materials that can be taken home after the consultation, some Materials might have an influence on their working capabilities.

Admit/Transfer

• Click on the Admit/Transfer To drop-down menu for additional options.

• Hospital: The Patient will be admitted to a Hospital.
• Ward: The Patient will be transferred to a Ward in the Hospital.
• ICU: The Patient will be transferred to the Intensive Care Unit.
• HC: The Patient will be transferred to High Care.

• Type the name of the facility to which the Patient is being transferred in the Facility Name field.

• The Facility Name field is a free text field.

• Click in the Mode of Transportation field and type the mode of transport the Patient will take to travel to the Hospital/Facility, such as Self/Ambulance (ER24/EGM/NC911/other)/Helicopter/Friends/Family/Police/Employer. 

• The Mode of Transportation field is a free text field.

Specialists

• Click on the Add Specialist button.

• Additional fields will appear. 

• Click on the drop-down menu in the Select a Speciality field. The speciality would be the type of Specialist the Patient requires, such as a Cardiologist.
  

• Click on the relevant Specialist Type from the drop-down menu.

• Type the name and surname of the Specialist in the Specialist Name field.

• Alternatively, Click on the Search External button. 

• The Medibase Search screen will open, where the user can search the name of a specific Specialist if they have been linked to the Medibase.

• For more information regarding the Medibase Search, please refer to the user manual: Medibase List Search.

• Click on the Close button to return to the Diagnosis and Plan panel.

• Click on the - button, which will permanently remove the current row of Specialist information.

Outcome Note

• Type in the conclusion of the Patient's case in the Outcome Note textbox.

• Type in any information that the referred Practitioner might need to know. Handover Note is a free text field.

• Click on the Close button to exit the Clinical screen without saving.

• Click on the Save and Close drop-up arrow for more options: