Clinical - Procedures
In this article the Clinical Procedure, you will learn how to manage a record of medical procedures for patients, create new procedures, and edit, print and delete existing procedures.
*Note: Procedures are limited to users with a Specialist MediRecords Subscription. If you do not have this type of subscription, Procedures will not be visible or accessible within the patient's clinical record.
The Procedures page in a patient's clinical record displays a summary of all the medical procedures recorded for that patient. From within the summary, you can quickly view the date of the procedure, type of procedure, the side of the body, the magnitude, the provider who performed the procedure, the consultation room where it was performed, and the current status of the procedure.
To quickly filter which procedures you can see in the summary, click Filter to reveal a drop-down list, can select either Active or Inactive.
To search for a procedure, click the Search box and type in a Keyword in the Name of the procedure. Press Enter and the system will display a list of the closest matches.
You can also search for procedures by Provider Name.
*Note: Searches are case sensitive
To Add a New Procedure, click New Procedure to open the procedure form.
The procedures form has three separate tabs - Admission, Clinical and Outcome. When creating a new procedure, the form opens on the Admission tab.
Click Procedure, and type in the First Few Letters of the name, and select the procedure from the list.
Click the Left, Right or Bilateral tick-box to select the location.
Click Provider and select the user. Click Location and select the procedure room at your clinic. Click and add the Appointment Type and Length and the Admission Date and Time, then click Save.
Complete the rest of the form with all the required details. To add the procedure to the consultation notes, click the Add to Today's Notes tick-box. To make the record confidential, so that only you can see it, click the Confidential tick-box.
To add clinical details to the procedure, click the Clinical tab (optional), or click Save to finish (and skip the next step in the tutorial).
Complete the Clinical section of the form with all the required details, and click Save.
The newly created procedure will now be visible in the Procedures summary.
To Add an Outcome to a Procedure, click the Tick-box next to the name to reveal a list of options. Click Edit to open the observation form.
Click the Outcome tab, and complete the form with all the required details, and then click Save.
Add Discharge Date if necessary and click Save
To Print a Summary of Procedures, click Print to open a print preview.
Check to make sure the page is going to right printer destination, select Layout and Color if required, and click Print.
To Edit a Procedure, click the Tick-box next to the name to reveal a list of options. Click Edit to open the procedure form.
Edit the form as required, on any of the Three Tabs, and click Save to apply the changes.
To Delete a Procedure, click the Tick-box next to the name to reveal a list of options. Click Delete to permanently delete the procedure from the patient's record.
Click Yes to acknowledge the procedure will be deleted.
To Delete Multiple Procedures, click the Tick-box next to the names to reveal a list of options. Click Delete to permanently delete the procedures from the patient's record.
Click Yes to acknowledge the procedures will be deleted.
To Print an Admission Card, click the Tick-box next to the name to reveal a list of options. Click More to reveal a drop-down list, and then click Print Admission Card to open a print preview.
Check to make sure the page is going to the correct printer Destination, select Layout and Color if required, and click Print.
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