Description

This section is utilized to document the patient's Chief Complaint during a clinical evaluation. It includes a pre-configured set of options, however, users have the flexibility to add, modify, or delete these options according to their requirements


Configuration

  • Settings / Clinical / Clinical Evaluation Template: From the settings menu, same as if on the screen itself, right click to add, modify or delete options.


Access 


Through the Side Bar section: To access the Chief Complaint button, click on it in the Side Bar of the Progress Note screen. If the Chief Complaint button is not visible, click on the Settings button on the Progress Note screen's toolbar. Then, choose the Side Bar Settings option. From the available items on the right, select the Chief Complaint and drag it into the items window on the lower left corner under any Side Bar category. Click the Save button to apply the changes. The Side Bar will update, and the Chief Complaint button will now be displayed in the chosen category.

Through the Search section: Click on the Search button located on the left side of the screen, then select the Chief Complaint button.

Through the Clinical Evaluation section: Select the "Chief Complaint" or "Present Illness" option in the Clinical Evaluation section.

Buttons

  • Physical Examination: When pressed, it displays the “Physical Examination” screen, for easy access to record any injury, trauma, among other things at the physical level of the patient. 
  • Procedures Templates: When pressed, it allows you to add “Templates” of procedures to the clinical evaluation of the patient. 
  • Refresh: Pressing updates the evaluation options.
  • Leave Note Open: When pressed, it allows you to leave the progress note open, without having to return to the patient's progress note screen.
  • Order Set: When pressed, it allows you to manage the “Order Sets”, without having to return to the patient progress note screen.
  • Load Last: Brings the options used in the last progress note.
  • Save As Template: Allows you to save the options pre-filled by the provider, so that they can be used with other patients.
  • Select Template: Allows you to select “Template”, previously saved.
  • Save: Save the selected options in the progress note and copy them to the “Clinical Evaluation” section of the “Advanced Progress Note” screen.
  • Cancel: Cancels any information previously recorded.
  • Show Previews Notes: When pressed, a column will be displayed that allows the user to preview the clinical evaluation before saving it.
  • Show Search Panel: Section where the search is performed among the options available on the screen.
  • Sort: Allows to sort the options by:

    • Sort by custom order: Selecting this option allows you to sort the options as they were registered.

    • Sort alphabetically: Selecting this option allows you to arrange the options in alphabetical order.

  • Filter By Patient: 
  • High risk of falling: Select this option if the patient is a person prone to fall. (This field will be displayed as long as the office or facility is not identified as an emergency room).
  • Life expectancy is 6 months: Select this option if the patient has an estimated time to live of 6 months. (This field will be displayed as long as the office or facility is not identified as an emergency room).


Secciones 

  • Patient Name: Display the patient's name. 
  • Age: Patient's age. 
  • Gender: Patient's gender. 
  • Record No: Patient's record number.
  • 4 Grids: In the tables, the different options for patient evaluation will be displayed.
  • Templates: Allows you to select a “Template” for patient evaluation.
    • Apply: When pressed, it will display the selected “Template”.
    • Clear: Pressing will remove the selected “Template”. 
    • Load Last: Pressing it will display the last “Template”.


Edition Screen

This screen will be displayed by pressing the right mouse button.


Deployment in the information record

The information saved in this tab will be displayed in the “Advanced Progress Note” screen, in the “Clinical Evaluation / Chief Complaint” section.