Description

Section used for the search of screens for the clinical evaluation of the patient.

Access

Through Main Menu

• Click on the Clinical button, in main menu. 
• Select the patient from any section of the screen.
• Once selected, click on the Search button, located at the top left of screen. 

Sections

• Search: Allows you to search for the screens.
  • ABG: Displays the screen, to record the information about the patient's blood gas analysis.
  • Active Tasks: Displays the screen of the patient's pending clinical tasks. 
  • Add Allergies: Displays the screen, to record the patient's allergies.
  • Add Immunization: Displays the screen, to record the patient's administered vaccines. 
  • Add Order: Displays the screen, to add patients orders. 
  • Add Order Result: Displays the screen, to record the patients results orders.
  • Add Problem List: Display the Select Code screen, to record the patient's active diagnosis.
  • Add Referral: Displays the screen, to add patients referrals.
  • Add Result Template: Displays the screen, to print the Templates of the order results.
  • Add Vital Sign: Displays the small screen, to record the patient's vitals.
  • Addendum / Amendments: Displays the screen, to record the patient's Addendum notes. 
  • Alerts: Displays the screen, of the patient's clinical alerts.
  • Anticipatory Guidance: Displays the screen, to record pediatric patient preventive care information.
  • Blood Sugar: Displays the screen, to record the patient's blood sugar level
  • Calls: Displays screen, to record the calls made by the patient.
    
  • CCD: Display the Patient Summary screen.
  • Chief Complaint: Displays screen, to record the patient's symptoms and main complaint. 

  • Clinical Report: Summary: It displays the screen, which allows you to create reports on the patient's clinical information.

  • Clinical Support: Displays screen, to search for educational information on any topic in order to be sent to the patient portal. 

  • Clinical Tasks: Displays the screen, to record the patient's clinical treatment. This screen works in conjunction with the Workflow screen.
    

  • Custom Alerts: Displays the screen to configure clinical alerts for the selected patient.
    

  • Custom Evaluation: Displays the screen, to record a specialized evaluation, previously configured.

  • Delivery History: Displays the screen, to record pregnancies and previous abortions of the patient.
    
  • Development MileStones: Displays the screen, to record the development information of the pediatric patient.
    
  • Documents: Displays the screen, to register patient's clinical documents. 
    
  • Drug Prescription: Displays the screen, to create prescriptions. 
    
  • Education: Displays the screen, to register and deliver educational information to patient.
    
  • Evaluation Forms: Displays the screen, to record and save the patient's questionnaires.
    
  • Evaluation Notes: Displays the screen, to record specific notes on patient assessments.
    
  • Export Progress Notes: Displays the screen, that allows you to select, print and save in PDF format, the selected progress notes.
    
  • External Imaging: 
    
  • Family History: Displays screen, to record the patient's family history. 
    
  • Immunizations: Displays the screen, to record the patient's administered vaccines.  
    
  • Implantable Devices: Displays the screen, to add or edit on medical devices.
    
  • IV Manager: Displays the screen, to record the serum administered to the patient, as part of the treatment.
    
  • Main Allergies: Displays the main allergy screen.
    
  • Main Orders: Displays the main orders screen.
    
  • Medication History: Displays the screen, to record the patient's active medications.
    
  • Menstrual History: Displays the screen, to record the patient's menstrual history. 
    
  • Optimal Instrument: Displays the screen, where the instrument that measures difficulty was transferred through 22 options, which a patient needs, to carry out various functional activities.
    
  • Order Set: Displays the screen of orders already configured, for a specific diagnosis.
    
  • Past History: Displays the screen, to record information about the patient's past history.
    
  • Patient Notes: Display the screen to record documents related to the patient's medical history through templates.
    
  • Patient Summary: Displays the screen with the patient's summary clinical information.
    
  • Pediatric Charts: Displays the screen, where it shows the different growth charts of a pediatric patient.
    Physical Exam: Displays the screen, to record the information about the physical examination performed on the patient.
    
  • Physical Examination: Displays the screen, to record injury and / or trauma, at the physical level of the patient.
    
  • Physical Therapy: Displays the screen, to record and save the patient's physical therapies information. 
    
  • Care Plan: Displays the screen to record the patient's care plan. They will contain the Snomed code, so that they can be included in the CCDA.
    
  • Pregnancy: Displays the screen, to record the patient's current pregnancy and her prenatal visits information. 
  • Procedures: Displays the screen, to record the procedures performed on the patient.
    
  • Procedures Imaging: 
    R.O.S. (Review of System): Displays the screen, to record the information for the review of the patient's systems.
    
  • Rule Outs: Displays the screen, to configurate and select all patient's exclusions of a diagnosis or condition. 
    
  • Signatures: Displays the screen, where it shows all the users who have intervened and saved information in the patient's clinical evaluation. 
    
  • Sleepiness Scale: Displays the screen, to record the patient's sleep scale.
    
  • Smoking Status: Displays the information, to record information about the patient's smoking status.
    
  • Tasks History: Displays the screen, where you can view the history of the clinical tasks assigned to the patient.
    
  • Triage: Displays the screen, to register the information about the symptoms of the patient, for whom you arrived at the facility or office. Usually this information is registered by the nurse.
    
  • View Orders: Displays the screen, where you can see and print the patient's orders, referrals and prescriptions.
    
  • Vital Signs Main: Displays the main screen, to record the patient's vital signs.
    
• Close: Closes the section.