3.3.1 Business Applications: MD

Transcription

1 Getting Started 1. To begin, double click the MD3 icon on your desktop 2. The MD License window will appear, click I Agree Access Levels: Medical Director has two separate types of access: Doctors: Full access to MD & Patient Records Non-Doctor Access Levels: Security Access Levels, determine which features non-doctor users have access to Sample Database A Sample database is available within MD, containing Patients Files that have been designed for testing commands. You can use the Database & make changes to Patient Files without it interfering with Live Patient Files. To open the Sample Database: 1. Select Sample Database from the drop down arrow in the Configuration field. Then select a Practitioner name listed in the User Field & enter the appropriate password & click OK Definition of Non-Doctor Access Levels: FULL: Access to Patient records & the ability to add/edit history, immunisations, Pap test & antenatal data. Print summaries, & write, save & print correspondence. Medications cannot be added, changed or deleted. Investigation requests & medication summaries can be created, requiring a doctor s signature for validation. Pathology results cannot be checked. LIMITED: read-only access to Patient records. Can create letters containing Patient data. User Dr. A. Practitioner Dr. I. Feelgood Sally Physio Password password password physio BASIC: Read-only access to demographics. Cannot open Patient records.

2 Patient Records: The patient select window will appear once MD is opened. Simply start by entering the surname of a patient & select from the list by clicking on their name & then click OK To open multiple Patient files, click on Patient & select Open Another or press Alt + F2 on your keyboard Where there are multiple Patients with the same surname, enter a partial surname followed by a comma & the first letters of the given name (e.g. entering Andr,J finds the Patient Andrews whose first name begins with J ) You can also open Patient files by selecting Patient & Open or press F2 Search for the Patient & select OK to open the file

3 The Clinical Window The Clinical Window has an Upper Half that contains demographic & other details about the Patient & the Lower Half contains various tabs relating to the Patient s health care. By double clicking on a section in the Upper Half of the screen, you can open the Patient Details window to update information Patient Demographics Other Demographics Smoking Status Consult Time ATSI Status Allergies/Warnings Recalls Health Care Tabs Display Window

4 There are toolbar buttons running along the top & bottom of the Clinical Window which you can use to perform the following:

5 Health Care Tabs 1. The Summary tab gives you a brief overview of the Patient s history, current medications, immunisations, family & social history, & preventative health information Medications that have a symbol in the # column will be only printed once & include: - Prescribed for a limited period of time/treatment - Prescribed for a limited period of time/treatment that has expired - Compliance waring for long term meds that have elapsed - Compliance warning for limited/long term meds that have elapsed - 7 days until elapsed date/time You can select a medication from the list & right-click to open a menu of options 2. Within the Current Rx tab, you will find the current medications prescribed to the Patient Medications that have a symbol in the * column are waiting to be printed, such as: Script waiting to be printed - Hand written script waiting to be recorded

6 3. The Progress tab is where you record notes about the Patient s visit & can be used to see details of previous visits. It is divided into two sections: 4. In Past History, you will find a summary of the Patient s medical history. Selecting an item & right-clicking will display an option menu Current Visit Previous Visits Details of each Visit Comments related to past history entry Filter for viewing past history records 5. The Results tab is used to record & display investigation results. All results are displayed according to the date an activity was performed. You can choose to filter results by clicking on the drop-down box Notes can be recorded in the Current Visit section. Automatic text will also be recorded in this section The Previous Visits drop-down tab allows you to view recorded notes according to the reason for contact By right-clicking within the Results tab window, you can open an option menu (as displayed above)

7 The View Result option will open a window & display further details about the result You can also recall the Patient by clicking on Add Recall & filling in the appropriate details in the window The Add Result option allows you to enter a new investigation There are options to Delete a result or Move Result if it is recorded in the wrong Patient File Click on Mark as Notified once a Patient has been notified of their result. This will then be recorded in the Progress Notes The Cumulative Results button allows you to view a series of results

8 6. The Letters tab displays Patient documents that have been created & received using Letter Writer To create a new letter, select New Letter to open Letter Writer. Once open, click on File & then New to begin a new document Details of document Search Button Document Preview 7. Within the Old Scripts tab, you can view all hand-written & printed medications that have been prescribed to the Patient By selecting a document & right-clicking, you can open an option menu & select Edit Letter Details to update the details of a document The Show Deleted Scripts will display deleted scripts, the View button will display a description of the prescription & the Prescribe button can be used to write another prescription of the selected medication

9 8. The Immunisation tab will show a record of the Patient s immunisation & vaccination history Within the Documents Tab, you will find an area to import documents into a Patient s file, such as images, word documents & ECG results You can right-click within the window to open an option menu & choose to edit an immunisation/vaccination record The Edit button provides you with options to edit the details of a document The New Item option allows you to add an immunisation/vaccination record You can look at the document by clicking on the View button or doubleclicking on the document

10 9. The Pap Test tab is included in Female Patient records who are 15yrs or older. All pap tests will be displayed with the date of the test, the result & the presence of endocervical cells &/or HPV changes To add a new pregnancy, click on the New Pregnancy button to open the Pregnancy Calculator 10. The Obstetrics tab is included in Female Patient records who are 15yrs or older. The window is divided into two sections: Information about Patient s Pregnancies To record an antenatal visit, click on the Record Visit button to open the Antenatal Visit window Record of antenatal visits for selected pregnancies

11 Click on the Past Pregnancy button to open the Past Obstetric History window The Parity button allows you to record parity details about the Patient Common Tasks: Click on the Path. Results button to open the Pregnancy Pathology Results window Editing Patient Details Click on Patient & select Details or Crtl + D. A window will open with several tab across the top, providing you with the ability to edit

12 Recalls Click the Ringing Phone icon to view a list of recalls for the Patient Clicking on History opens a window allowing you record Patient information with minimal typing by simply clicking yes/no & ticking boxes. You can also access the Patient Details window & update information by clicking on the Open Family/Social History Within this window, you will find options to print, add, edit, delete, update, view performed actions & view progress notes that were entered with the selected recall item Progress Notes History & Examination Within Progress Notes, you will find the History & Examination buttons Clicking the Examination button will allow you to perform a quick assessment with minimal typing by clicking yes/no & ticking boxes

13 Patient Searches: Patient Database The Patient Database lists all active, inactive & deceased patients. To view the Patient Database, go to the main screen in Medical Director & click on Patient & select List or press F10 on your keyboard The Asthma Search window will appear & you will need to fill in the search criteria & click Search Diabetes Register The Diabetes Register can be displayed by clicking Search & selecting Diabetes Register. All Patients with a diagnosis of Diabetes along with their activity items will be displayed Asthma Search Performing an Asthma Search will list all Patients who have had an asthma diagnosis recorded in their file. To begin the search, open the main window in Medical Director & click on Search & Asthma

14 Clinical Assessments: ATSI Health Assessment From within the Patient s Clinical Window, click on Assessment & select ATSI Health Assessment. The Health Assessment will open & you will need to complete & Save once finalised Asthma Action Plan This tool is designed to assist Patients to manage their asthma. Click on Assessment & select Asthma Action Plan. A Current Action Plan will be displayed if one has been performed

15 Care Plan A Care Plan is a record of a Patient s treatment being delivered by multiple health care providers. Click on Assessment & select Care Plan to open the Obtain Patient Permission & begin the Care Plan Diabetes Record A Diabetes Follow Up tool is available by clicking on Clinical & selecting Diabetes Record. This can be used to assist with the management of a Patient s diabetes condition. You can begin a Diabetes Assessment by clicking on Assessment, add values for height, weight, BGL & other biochemical information & print information by double-clicking on a date Click Save once complete & Print

16 Diabetes Assessment The Diabetes Assessment can be accessed by opening the Diabetes Record (as detailed in previous step). For further Help, click on the Help tab along the top ribbon Notes: