Examination
The Examination module is the Health Summary details of the patient's medical and physical examinations. Vital Signs are the indicators of a patient’s general physical condition. It identifies a patient’s level of physical functions based on elements such as heart rate, pulse, blood pressure, and body temperature.
SOAP notes are written to facilitate improved communication among all, involved in caring for the patient and to display the assessment, problems and plans in an organized format.
Subjective: This describes the patient's current condition. These are symptoms the patient verbally expresses or as stated. These subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness, when the problem first started.
Objective: An objective observations include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests.
Assessment: The assessment represents the physician’s conclusions and working assumptions that will guide the treatment of the patient. The assessment is used to formulate a specific set of recommendations. The assessment may be a list of specific disease entities.
Plan: The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions (e.g. elevate foot, RTO 1 week), and follow-up directions for the patient.
ICD-10 Diagnosis
Diagnosis Codes are used within the healthcare industry to identify specific medical diagnoses of patients receiving treatment. The code that are used in this section is International classification of diseases Version 10.
Review of Symptom(s)
The review of systems is an “inventory” of body systems where the patient is asked to report signs or symptoms they are currently having or have had in the past. The recognized systems include constitutional, eyes, ears nose mouth and throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurological, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic.
Select Examination in the Side menu of the Patient Module, which opens the Examination page.
Action controls
How to add New Examination?
To add Diagnosis, Select a Patient record >> Examination >> Create New Button. This link will open the add new examination page with four tabs, Physical Examinations, Diagnosis, ICD-10 Codes and Review of Symptom(s). In Physical Examination, you can add in new vital signs and soap notes.
The second section, Diagnosis, is where you enter the actual diagnosis and its primary and secondary stage details. In third section, ICD-10 Codes, is where you can add ICD-10 Diagnosis code & its description. Click + icon and select search button, which opens the list of ICD-10 Diagnosis codes. You can choose to search by Code or Description. Once you find the code, double-click or select ok, to add it in the Add Diagnosis page. Enter Start Date, End Date, Comments and then Save.
The fourth section is Review of Symptoms where you can record any problem areas in the respective section and Save.
How to Edit Examination?
Search and Select the Examination, which need to be edited. Double click the selected Examination, or Select Edit tab in the actions menu, which leads to the Edit Examination page. Change the required fields in the Edit Examination page, and Save to update the changes.
How to Delete Examination?
Search and Select the Examination, which need to be deleted. Select Delete tab in the actions menu, which leads to the Delete Examination confirmation page. Click Delete, which deletes the selected Examination.
How to Print Examination?
Search and Select the Examination, which need to be printed. Select Print tab in the actions menu drop down, which leads to the Print Examination page. You can review the Examination in this page, and download it to your system or print it. Click Close to return to the Examination Page.