The patient record is where you will spend most of your time in the EMR. It is, therefore, necessary you understand well the elements that compose it and the possibilities it offers.
The patient record contains all clinical notes filled for the patient, his results, medications, requests, vital signs, life habits and social context, allergies, clinical tools, programs, immunization and vaccines, problems, past medical history, and family history. When a healthcare professional sees a patient, he starts a clinical note in which he adds all observations and tests. The patient record allows the backward-tracing of everything made or completed for the specific patient when the consent is active. The QHR is also available through the patient record, and a patient documents list can be printed.
Understand the Administrative center elements
The patient Administrative Center contains all information to identify and join the patients, as well as other administrative data. It is also in that section that you can add the patient's file number. To access the Administrative center, you have to click on the patient icon at the left of the patient's name.
Knowing that all professionals work differently and in order to optimize your daily practice, it is possible to rearrange the order of the summary boxes in the patient record. By doing this, you can choose to put the clinical tools on top, the vital signs lower and so on to accelerate your processes. An icon on top of the summary allows you to do modifications.
The patient's search in Omnimed allows you to find patient records in the application. The search box is situated on top of the EMR at all times and from everywhere. To search effectively, you can use the record number, the HIN, the first name and last name, the date of birth, or the phone number as well as a combination of them.
Add a clinical note
To start a new clinical note in the patient record, you have to click on consultation reason. Once the note is started, you can choose the note type, add documents, write content, add clinical tools and add vital sign results or any modification in the patient's profile.
Fill a clinical note (entry methods)
Once you started the clinical note, you can use your keyboard to type the note content, but you can also use other entry methods such as voice recognition or macro functions with software like Dilato, Text Expander, or others.
Modify/delete a clinical note
By clicking on a clinical note's title in the patient record, it opens it and you can then modify it. To delete the clinical note, you need to follow the steps to modify it, delete the consultation reason, the tags, and its content, and then save it. If you do not find the clinical note you are looking for, it may hide behind the eye icon that filters the notes. The notes that appear straight away in the patient record are the ones with a consultation reason, tags, consultation details, or a conclusion. The others hide behind the eye, so you have to click on it to deactivate the filter.
Understand the clinical note
To accelerate the typing of a clinical note and to integrate practice standards, we developed a section in the clinical note to offer what we call clinical tools. The clinical tools regroup standard follow-up and evaluation forms (CNESST, insurances, APSS, obstetrical files, etc.), calculation tools (Framingham score, Cockcroft-Gault, etc.), anatomical charts, and note templates. Clinical tools have also been developed for some administrative regions and can be found in the Requisitions - XX category (where XX stands for the administrative region).
As soon as a clinical tool is opened, it is included in the clinical note you were already in. You can retrieve it in the clinical note or in the Clinical tools module in the patient's record summary.
Notes review module
The Notes review module allows you to see all notes in redaction from the healthcare professionals in your institution. While typing the note, you can save it to complete it later, complete it right away or send it in through a task to a professional in your institution. The saved notes appear in the Notes review module in the left menu. Then, at the end of the day, you can easily consult all saved notes to complete them.