Advanced Point-of-Care Clinical Information Solutions and Services
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Advanced Point-of-Care Clinical Information Solutions and Services |
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Above are sample sections of the Crisis Initial Assessment Form. medEntry allows the user to chart by exception i.e. only enter information that has changed for the patient. For example, just before this form is displayed, medEntry asks if any information should be copied forward from previous encounters to this new form. If the user answers affirmatively, certain pre-defined data items are filled in automatically. This is especially helpful when recording the patient's individual and family history, previous hospitalizations, etc. If someone has already documented this information, the user can simply with a single click copy it to the current form and then update just the things that have changed. The original document from which the information was taken is unchanged, and the current document contains a complete and up-to-date record of the patient with minimal time and effort by the provider. This form, as with any MsdC form, can be as brief or as complex as necessary. Even a very detailed form can be completed within minutes with medEntry's timesaving features. When the user selects Yes, No or Other with detail for a data item that has additional or hidden information, the additional information is immediately opened. In these examples, expanded information for Alcohol Substance Use, Orientation, Oriented and Behavior are opened when the users selects an option that contains additional detail. The expanded information is indicated by a arrows on the left side of the window. This functionality speeds data entry by allowing the user to only view detailed data fields required for each patient. Each section can be as general or as detailed as required by the provider, practice or hospital. In a teaching environment, the subscreens can be very specific to remind new physicians-in-training of symptoms to consider in making a diagnosis. In a less structured practice, the subscreens can be very minimal and may only include a notes field. Many fields have a "Notes" button available. Any additional data that is not fully addressed on the form and its subscreens can be detailed in the free text editor and displayed on the form. On the Diagnostic Impressions section the user added additional comments for the Axis I and Axis II Impressions.
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