Every time a patient visits the doctor, it is the doctor's priority and duty to maintain a record of that particular visit. The health care provider records the reason behind the patient visit and important details like what observations were made by the doctor, medications prescribed, any specific instructions given, and much more.
Follow these steps to record a patient's medical visit.
How to create Patient's Health Record?
Option 1 - You can click on the [New Health Record button] available in the Patient account page.
Option 2 - You can click on the [New Health Record] button available in the Patient medical history page after searching and selecting the patient using their name, email, phone number, or kpid.
Option 3 - You can click on the [Patient Health Record] button available in the Doctor Appointment details page.
Customize EHR modules view :
- You can simply click on an module and drag and drop it anywhere in the page to customize the page according to order of your preference.
- Click on the Reset setting option from the dropdown for the page to return to its default view.
Show/ Hide Features:
- Click on the Show button available in the Health Record page to customize the view and to hide/show only necessary features.
- Once the hide/show option is used for a particular feature, it will remain as default for all new health records but previously saved data in those particular fields will be visible always.
Favorite: You can directly save a detail that you have entered to the favorite folder by clicking on the icon available in the window.
How to add?
- Click on the , and click on the button.
- To assign the detail to a label, click on add label and choose your preferred label to store the added details.
- Confirm by clicking on the checkbox available next to the label and click on the icon.
- If you need to create a new label, click on Create New Label from in the Select label window and create a new label.
- Add the name of the new label and click on the icon to create the label.
- To remove a label that has been selected, click on the icon available in the selected label.
- To save the details and add it to the favorite folder, click on the icon, and click on the to exit.
How to utilize the favorite item?
- Click on the to view the favorite item.
- Click on the available next to the saved details to add it to the list
- Click on top of the saved detail to edit or delete it.
- Click on the to view the label list, and select your preferred label to view and use the details saved in the label.
- Click on the icon to return to the main menu.
- You can rename/delete a label by clicking on the icon available in the Select label window
- You can add the same detail to many labels simultaneously.
- The details saved as favorites will appear in the most recent order in the favorite folder.
Follow-up: - A follow-up for the visit can be scheduled from the EHR page.
- Click the follow-up button available on top of the EHR page.
- Date : Click on the date field and select your preferred date from the calendar.
- Appointment : Click on the Fix Appointment button and select the preferred slot from the available time slots for the chosen date.
- Update the description if required and/or click on the [Save button] or to confirm the follow up appointment. Click on the to discard details entered and exit.
How to delete a Follow-up appointment?
- To delete a scheduled follow-up visit from the EHR page, click on the date.
- Follow-up: Click on the [Trash icon] available next to the Date and Time to delete.
- The follow-up option will be available only after the EHR ID of the current EHR is generated.
- Once the appointment is fixed, the details will be available in the appointment calendar of the Doctor and notifications will also be sent similar to when appointments are fixed from the Appointment page.
Export CCD - The complete CCD document of the patient can be exported.
How to export?
- Click on the in the Health record page.
- Click on Export from the dropdown.
- Once selected, the CCD-xml file of the patient will be exported.
How to complete Patient Health Record?
The health care provider can complete a medical record of a patient by signing, affirming that the particular visit of the patient is complete. After completion, the health record cannot be further edited, but it is available for viewing for future reference.
To complete a medical record, click on the complete button and authenticate by providing doctor's email ID and password.
- Doctor Email ID: The doctor's registered e-mail id should be entered here.
- Password: The doctor's password should be entered here.
- Date in Complete: Click on Past date medical history entry and select the preferred past date you prefer to record as the completed date of the EHR.
- Click on to save the details entered or click on discard to discard the details entered.
- When a health record is completed by the health care institution for a patient, an email/sms will be sent to their registered email id/phone number [if provided by patient] along with the completed health record link.
- A unique EHR# ID is generated for each health record, which helps the health care provider to track the health record for future reference.
- Once the Health record is completed, a notification message with the link of the completed EHR will be sent to the already selected user[s] in the Notification panel available in the settings page. This notification message will be sent via the 75health message module.
- Once you complete any EHR date and time, it will be displayed in updated option given in the top of the right side in the health record.
- Click on the print icon to print details.
- Block View: This option will enable users to print details in the block view.
- Row View: This option will enable users to print details in the row view.
- Select Modules: This option will enable users to select the preferred modules that need to appear in the print.
- Don't print Unused Modules: This option will enable users to print details of only modules with health record details.
- A sample preview of the document to be printed will be always be visible here.
- Once completed click on the Print button to confirm the changes and proceed to print.
- The changes made to the print preference will be stored as the default print option for all future prints, until updated by the user.
How to print the Prescription/Vaccine/Test Order?
- The print option can be used to print the Prescription/Vaccine/Test order of the patient for various purposes.
- Click on the Print button available at the bottom of each health record and select Prescription/Vaccine/Test order to print the details.
Time Stamp:- This feature once enabled will help you view the details of the User, Date, and Time of adding details to the Vital, Procedure, Test Order, and Note modules.
How to Show/ Hide Timestamp?
- Click on the Show button in the bottom of the EHR page and click on the Show/ Hide Timestamp option.
- The timestamp will be automatically activated once details are added to the Inpatient module.
- The Show/Hide Time stamp option will be automatically activated once the inpatient details are added to an EHR. It can be hidden once you manually select hide timestamp.
- Once the hide/show option is used for an EHR, the feature will be activated only for that particular EHR.
- The timestamp feature will be available only for the Vitals, Test Order, Procedure and notes module.
Reset Setting: - You can reset all the changes made to the EHR page view to return to the default view.
How to Reset Setting? - Click on the Show button in the bottom of the EHR page and click on the Reset setting option.
QR Code: - You can scan the QR code using a mobile or scanner to share/ view the EHR and profile information of this patient.
- Using this feature, the patient/ user can share the EHR/ patient profile information from their respective logins to a different hospital or to another device using the 75health EHR platform.
- The user if already not logged in will be requested to login to their 75health User account to successfully view the scanned information.
- The same QR code will be available in the print copy of the EHR.
- QR code will be available in the following places: Login page, Patient profile, Patient id card and health record.
- QR code will be enabled in new health record only after entering any data in the new health record.
- Click on the delete button available in the bottom of the EHR page and confirm by click on OK to delete or click on CANCEL to exit.
- Once confirmed to delete, details added to this EHR will be completely erased along with the EHR ID.
- Click on the Generate Bill button or the dropdown.
- Click on the Generate Bill button billing button or choose Generate Bill option from the dropdown to directly navigate to the Invoice page to generate the bill for the current EHR..
- Clicking on the Generate Bill button and selecting the Generate Bill from EHR option from the dropdown will automatically assign all billable items from the current EHR to the invoice.
- This button will be available only once after the EHR ID is generated.
- The details added in the EHR will be available under the Used in EHR section in the Invoice page when the Generate Bill option is selected.
- The pricing details will be available only for the Prescription, Test Order and Procedure details added in current EHR.
- Once the Generate Bill option is used, the Generate Bill button will be replaced with the Go to Billing button.
- Clicking outside/anywhere after adding data to any module will help you to save the details included. The Save/ Save & Add button will also allow you to save details.