Description

Screen configured to provide clinical users with clinical evaluation options to document a patient encounter and maintain a patient's medical history. Documentation stored in all of the evaluation segments is presented on the Clinical Evaluation window of the progress note screen.


Access 

There are three ways to access this screen. 

  • Through the Side Bar section: To access the Custom Evaluation button on the Progress Note screen's Side Bar, click it. If the Custom Evaluation button is missing, click the Settings button on the Progress Note screen's toolbar. Then, choose the Side Bar Settings option. From the available items on the right, drag and drop the Custom Evaluation item into the lower left items window of any Side Bar category. Click Save to apply the changes. The Side Bar will update, and the button will be displayed under the added category.
  • Through the Search section: Click on the Search button located on the left side of the screen, then select the Custom Evaluation button.
  • Through the Clinical Evaluation section: Click on the "Custom Evaluation" text within the Clinical Evaluation section.


Sections


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, 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 the "Template", previously saved. 
  • Save: Save the selected option 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: Display the patient's age.  
  • Gender: Display the patient's gender.  
  • Record No: Display the patient's record.  
  • 4 Grids: In the tables, the different options for patient evaluation will be displayed. 
  • Templates: Allows to select a "Template" for patient evaluation.
    • Apply: When pressed, it will display the selected template. 
    • Clear: When pressed, it 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.