Patient Records
Patient Clinical Record Conventions

Tabs

  • Some Service Records use Tabs to divide up data across the screen, to avoid the need for scrolling down (and up) the service record window.

Non-editable selection lists

  • Many text selection lists (drop down lists) contain a fixed set of entries, one of which can be selected by the user (or must be selected by the user if the field is mandatory).  It is not possible to enter any value other than those in the drop-down list.

Editable selection lists

  • Editable text selection lists (drop down lists) allow users to type their own text into the field if the options in the drop-down list are not appropriate.  Text that is typed in by users is not added to the drop-down list options (please ask Smart Health to add options to a drop-down list if this is required).

Mandatory fields

  • Mandatory fields are highlighted in yellow or contain the word "Required" (or the letter "R").  Service records that support draft and final versions can only be saved as “final” when all mandatory fields have been completed.

Fields with invalid data

  • Fields that contain invalid data are highlighted in pink, or with red surrounds, for example when numeric field data is outside the allowable values for the field.

Dates

  • Dates can be entered in several ways, including using a drop-down date picker or typing the date directly into the field using one of several standard conventions.  When typing dates (and times), slashes between day, month and year are optional, colons between hours and minutes are optional and year can be in “yy“ or “yyyy“ format. Some date fields accept partial dates (year or month and year only).

Check boxes

  • Check boxes are used to broaden the selection of displayed service records. For example, when the Medication Summary is selected, it displays current medications only by default.  Selecting the Display All check box also displays historical medications.

Edit

  • Service records that can be edited have an Edit button at the bottom of the screen.  In some cases, separate groups of fields within an on-line form may be editable.

Close

  • Service records have a Close button that can be selected to close the record (to de-clutter the patient view).  It is not necessary to Close patient records before closing the patient.  If you close a patient while unsaved service records are open, you will be reminded to save those service records before the patient is closed.

Cancel

  • When a service record is being created or edited, or a dialog has been opened to enter service record data, a Cancel button can be used to cancel the current action and return to the previous state.

Save

  • The Save button, displayed when a service record is being created or edited, saves the service record to the Smart Health database.  Service Records that support draft and final versions can only be saved “final” when all mandatory fields have been completed.

  • Saving a service record as "final" usually causes a copy of that service record to be sent to the local EMR/SMR/DMR.

Save draft

  • Some service records can be saved as Draft records.  A Save button is displayed in addition to a Save Final button.  Service records that support drafts can be saved as drafts while mandatory fields are incomplete.

 
Confidentiality
  • Some health event records in Smart Health have a Confidentiality setting that is assigned when the record is created.

  • The default Confidentiality is Normal and this does not normally need to be changed.

  • In some circumstances, the Confidentiality of an event record may need to be changed to reflect the sensitive nature of information that has been recorded in that event summary:

    • Restricted - Only accessible by members of the creating medical group (practice), regardless of patient consent and other users’ permissions

    • Very Restricted - Only accessible by the creating provider, regardless of patient consent and other users’ permissions

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Standard Clinical Records

Medications

  • Medications in Smart Health are MIMS encoded (formulations, packaging, recommended doses), full and abbreviated product information and consumer medicine information).

  • The Medications view displays the patient’s current medications.

  • View all Medications (including historical Medications) by selecting the Show all medications check box:

  • View Medications for which the patient has had adverse reactions by selecting the Show adverse reactions check box:

  • View the history for a medication by double-clicking the medication (anywhere in the medication row).  The prescribing history is displayed in the lower pane:

  • Double click any specific instance of a medication to display the details in a separate tab:

  • To create a Medication, click "New" in the Medication Summary or select Medication from Main Menu/New Service.

    • To re-record a medication, select the existing medication and click New.  The medication form will automatically be populated with the details from the previous medication record.

    • New medication:

    • Select Advised to record medication details from another source of information.

    • The Indication field lists the patient’s known conditions.  If you wish to enter a new condition (for which a medication will be prescribed or recorded), click Conditions/Diagnoses (under Patient Details) to update the Problem List.  The new diagnosis will then appear in the list of Indications in the Medication form.

    • Type two or more letters of a drug name to display a list of drugs with matching names.

    • If you type in a non-MIMS drug name, you can save it as a non-MIMS medication (however, other fields in the medication/prescription record may be disabled):

    • Once you have selected a Product, you can click the Abbrev PI or Full PI buttons to display brief or full product information pages respectively.

    • There may also be a choice of formulations; when you select a formulation, the Dose Guide is displayed and there may be a choice of Pack.

    • When you select a Pack, the PBS/RPBS options for that Pack are displayed.

    • When you enter a Dose and Frequency, the form will automatically calculate an end date for the medication.

    • Click Save to save the medication record and add it to the medication summary.

    • Select a medication and click the Completed button to mark that medication as being finished (as of today’s date).

    • Select a medication and click the Cease button to end that that medication.

      • You will be prompted to select a reason for ceasing the medication, including an option to record an adverse drug reaction, which will be recorded for that patient in Smart Health.

  • Summary records present aggregated data in tabular form so that they can be easily viewed and monitored.  These views are not designed for entering or editing data – they make it easier to quickly review large sets of clinical data (like pathology results) without having to select many clinical event records to do so.

Conditions

  • Conditions in Smart Health are SNOMED encoded.

  • To view and updated Conditions, select Conditions in the Navigation tree.

  • Select a condition from the list of conditions to display additional information in the lower panel:

    • Click Edit to update the patient’s conditions.

    • Click Add to select a new Condition:

    • Type text in the Search/Additional field to select a Condition.

    • Select a Condition and click Select (or double click a Condition).

    • Enter additional details and click Save to save the Condition.

  • To display all conditions/diagnoses (including inactive conditions/diagnoses) select the Show All check box:

Procedures

  • To create a Procedure, select Procedure from Main Menu/New Service.

  • Select Procedures in the right-hand pane and click the arrows between the panes to add them to, or remove them from, the patient’s profile.

  • Select the Procedure List tab to display a Search field and find procedures by typing text in the search field.

  • Procedures are saved as clinical event records.

  • When all procedures have been entered, click Next.

Immunisations

  • To create an Immunisation, select Immunisation from Main Menu/New Service.

  • Select Immunisations in the right-hand pane and click the arrows between the panes to add them to, or remove them from, the patient’s profile.

  • Additional information relating the selected Immunisations can be added in the left-hand lower pane.

  • Select the Immunisation List tab in the right-hand pane to display a Search function to find Immunisations:

  • Immunisations are saved as clinical event records.

  • When all immunisations have been entered, click Next.

 

 
 
 
 
 
Selecting Providers and Medical Groups
  • Providers are selected using a tool that displays lists of providers and practices (medical groups) that are in the Smart Health provider directory.  For most service records, the list will default to providers from the logged in user’s medical group (practice) and may be limited to the roles that are appropriate to the field being selected.

  • Options allow users to:

    • Choose whether they wish to select a specific healthcare provider or a medical practice

    • Search for other providers or practices, and

    • Add non-participating providers and non-participating medical groups to the provider directory.

 

  • Care should be taken when adding providers and medical groups to Smart Health – please search carefully to ensure that the provider or medical group is not already in Smart Health.