Create a new entry in medical history

Revision as of 13:56, 21 December 2012

In order to create a new Medical History, Note or Attention Message click on the arrow at the right of the "New entry" icon and choose the option desired.

Creating a Note or an Attention message

When "Attention" or "Note" are selected the following window will open (the only difference will be the title area):

Explaination of the fields/icons:

Date: date of the registration of the document. If the lightning icon is clicked will be selected the current date.
By: author of the document or of the notes
QM: QM field icon can be used to access the QM fields associated to this document
Browse: clicking on the arrows will scroll the documents archived upwards or downwards
Text area: a "WordPad" like tool that can be used to input a text.
Container for pictures and documents: pictures and files can be easily linked to the document by dragging and dropping them into the blue box. Then they can be opened doble clicking on the icon.
Open patient directory: opens the directory that contains all the files related to the patient
Add document: allows to browse the directories and to add a single document
Open document: always to open the document added.

You can assign notes / attention messages to any patient. These are free text entries to which you can add date, status (normal/abnormal), name of the editor and a file attachment.
Notes / attention messages that are particularly important, clinically relevant or have to be edited still can be given the status "abnormal".
In the overview of the main window “Medical history” (Gyn or Andro) all notes / attention messages will be displayed (sorted by date). Their respective statuses can be seen on the right side of the overview.
Entries in the overview can be sorted or filtered by clicking the column headers. They can also be grouped by dragging them to the desired position. The changes will be saved and will not be lost.
Notes / attention messages can be edited again by double-clicking them. You can delete a note by selecting it and pressing the "DEL" key on your keyboard.

By clicking on "OK" the Note/Attention message will be created and published in the main page.

Attention messages will be in red whilst note will be in black.

Creating a Medical History

When "Medical History" is selected a window will open.

There are two different windows, one for the female patient the other for the male patient.

Creating a female Medical History

If "Medical History" is selected when the selected patient is a woman the following window will open:

<a href="/index.php?title=Free_/_QM_fields"><img style="display: block; margin-left: auto; margin-right: auto;" src="/images/QMButton.png" alt="" width="73" height="41" /></a>	Access the QM field section related to this area or click on the right arrow to block the QM fields or to see the change log.
<a href="/index.php?title=Create_a_new_entry_in_medical_history#Documenting_previous_pregnancies"><img src="/images/PreviousPreg.png" alt="" width="240" height="22" /></a>	Go to document previous pregnancies' outcome.
<a href="/index.php?title=Create_a_new_entry_in_medical_history#Documenting_examination_findings"><img src="/images/Exam.png" alt="" /></a>	Document examinations findings related to the Medical History.

On each section of the Medical History may be documented several data.
The fields with the red background have to be filled in order to fullfil the D.I.R. (German Registry for assisted reproduction techniques) requirements.
It is possible to customize the "Prior illness" and the "Sterility factors" modifing the related system tables.
From this page it is possible to access to the previous pregnancies section and to to the examination section.
When all the data you need to document are insterted just press "OK".
If exists at least one previous Medical History the system will ask if the user wants to take over data from the most recent Medical History.
If the date of the new Medical History is empty or younger than the date of an existing Medical History, the system will ask if the date of the first interview is to be updated to the date of the Medical History.

Documenting previous pregnancies

Clicking on the "Gravida:_Para:" link or on the red arrow icon will lead to the following window:

In the new window you will see a list of all pregnancies assigned to this Medical History.
To document a pregnancy just click on the button "New".
If you want to edit a pregnancy, "double click" on it.
It is also possible to remove a wrong documented pregnancy: just select it and click on the button "Delete".

If the anamneses are plausible, a green circle will appear on the right side in the column “Status”. Otherwise, a red warning symbol will appear.

Documenting examination findings

It is possible to link examination findings to a Medical History just clicking on the button "Examination" in the section "Female Medical History". The following window will open:

In the examination section it is possible to document several exames. If you want to import data from an existing examination, select the examination desired and press "Copy data" button. When all the data you need to document are insterted just press "OK".

Creating a male Medical History

If "Medical History" is selected when the selected patient is a man the following window will open:

Access the QM field section related to this area or click on the right arrow to block the QM fields or to see the change log.

A maximum of two basis semen analysis can be assigned to each anamnesis. There are two ways to do this:

Double click on the empty field or press the lightning icon to create a new semen analysis and link it to the Medical History.

Click at "Sperm concentration" if nor semen analysis is available.

On each section of the Medical History may be documented several data.
The fields with the red background have to be filled in order to fullfil the D.I.R. (German Registry for assisted reproduction techniques) requirements.
When all the data you need to document are insterted just press "OK".
It is possible to customize the "Previous illnesses" and the "Fertility impairment factors" modifing the related system tables.
If exists at least one previous Medical History the system will ask if the user wants to take over data from the most recent Medical History.
If the date of the new Medical History is empty or younger than the date of an existing Medical History, the system will ask if the date of the first interview is to be updated to the date of the Medical History.