Outpatient Clinic Folder

In the outpatient area unstructured information on visits is often stored in note form. The outpatient clinic folder supports this form of medical documentation by displaying these entries individually and connected chronologically. An individual entry in the outpatient clinic folder is known as an outpatient note.

Integration

The outpatient clinic folder is available in some standard aspects of the patient organizer (Quarter, Case, Total). The individual entries are displayed as outpatient notes in the tree of the patient organizer. All entries can be displayed in object folders in the corresponding aspects, the content is output in an HTML Control in the detail window of the patient organizer.

The outpatient clinic folder is configured using the progress documentation tool.

Prerequisites

The number range object for progress documentation is configured for the use of outpatient notes.

You can find information on this in the i.s.h.med implementation guide under IS-H*MED: Clinical Documentation IS-H*MED: Progress Documentation Define Number Range for Progress Entries .
Microsoft Internet Explorer 6.0 or a later version is installed on the work station PC.

Note

If you use the Internet Explorer in an earlier version than 6.0, it is not possible to display individual entries in the visible area by clicking on a tree element. Furthermore, undesired effects may result when you use user-defined stylesheets.

End of the note.

Features

The following functions are available for processing entries in the outpatient clinic folder:

Create

You create the first entry for a patient using the menu option Start of the navigation path Create Next navigation step Outpatient Note End of the navigation path in the patient organizer. You create further entries using Create or using the context menu of an existing entry.

Note Note

To work with the context menu, you must select the entry by clicking on the icon in front of the entry.

End of the note.

In the input screen you can enter notes and environment information such as the employee responsible (EmR), entering OU, reference date and time, description, which is displayed in the tabular view of the patient organizer. This information is preset with the context data of the patient organizer but can be changed. The information on the entry is distributed across the Administrative Data and Header Data tab pages.

Header Data Tab Page

The system will use the current OU from the context of the patient organizer to preset the documenting OU.

The user logged on to the system is preset as the EmR if he is entered as an employee of the OU. The EmR input help lists all employees of the current OU.

Reference Level

You can use the OU parameter N2OPD_BEZ to control the reference level when creating outpatient notes.

B Movement reference
F Case reference
O No reference (standard)

Reference date/time

You can use the user parameter N2OPDCHART to control the assignment to a visit (see i.s.h.med implementation guide under Start of the navigation path IS-H*MED: Clinical Documentation Next navigation step IS-H*MED: Outpatient Clinic IS-H*MED: Outpatient Clinic Folder Maintain Case List Parameters End of the navigation path ).

Parameter not set:

The reference date/time is preset with the current system time, since documentation is usually created promptly.

Parameter set:

The system will preset from an outpatient visit.

From the patient's case/visit list you select the desired outpatient visit or create a new outpatient visit.

The data is preset from the corresponding visit.

In case of reference-free creation, the current system time is preset.

Short Text

The short text is not preset. If the user has entered no text here, the system fills this field with the first 20 characters of the text entry when saving. The short text is displayed in the tabular view of the patient organizer in the Enhancing Description column.

The field for making the entry provides all possible options of the standard editor, and the use of text modules and markers is possible. New entries are automatically sorted in the tree structure of the patient organizer and in the detail view in descending reference date order.

The Entry Dialog

The following functions are available via pushbuttons in the entry dialog:

Release (Release)

Release

Checks and saves the entry, sets the release indicator and closes the entry dialog.

The release of an entry cannot be undone, released documents cannot be changed or deleted.

Save (Save)

Save

Checks and saves the entry and closes the entry dialog.

Cancel (Cancel)

Cancel

Closes the input dialog without saving.

You can modify the layout and range of input fields, you can find this procedure in the i.s.h.med implementation guide under Start of the navigation path IS-H*MED: Outpatient Clinic Next navigation step IS-H*MED: Outpatient Clinic Folder BAdI: Define Entry Dialog for Outpatient Clinic Folder Entries End of the navigation path .

Change

To change an entry, select the entry, and then choose (-) (alternatively, context menu, see Create section). You can then change the header data and the content of the entry.

You can only change entries that have not yet been released.

If you wish to change a released entry, you can create a supplement. You enter this supplement in the same way as a "normal” entry. The system assigns this entry to the same reference time and flags it as a supplement.

Display

The system will display the entries in the detail screen of the patient organizer.

To view an entry, select the entry in the tree of the patient organizer (alternatively, context menu, see Create section). In an HTML view you see all entries in chronological order, the most recent at the top. The entry selected in the tree is displayed at the top in the detail window. If the list is not completely visible in the detail window, you can quickly navigate to all entries using the scrollbar.

If you reselect an entry, that entry appears at the top of the detail window.

You can modify the layout and range of displayed data. The procedure for changing the filter values is described in the i.s.h.med implementation guide under Start of the navigation path IS-H*MED: Outpatient Clinic Next navigation step IS-H*MED: Outpatient Clinic Folder BAdI: Define View for Outpatient Clinic Folder Entries End of the navigation path . You can change the stylesheet to adapt the layout.

Delete/Cancel

You can use Delete (Delete) or the context menu to delete entries which have not yet been released, from the patient organizer.

You can cancel released entries using Delete (Delete) or the context menu. The system will not display canceled entries in the patient organizer.

Note that the system can delete or cancel several selected entries using the Delete/Cancel function called using the context menu. You should also note that the function call is restricted to the selected entries of one object type.

Print

To print one or more entries, you select them in the tree and then select Print (Print). You can also select entries in the detail screen and print them using the context menu of the detail screen.

The system prints using a supplied smart form, but you can also assign your own smart form.

You can modify the layout and range of printed data. The procedure for changing the filter values is described in the i.s.h.med implementation guide under Start of the navigation path IS-H*MED: Outpatient Clinic Next navigation step IS-H*MED: Outpatient Clinic Folder BAdI: Define Print Output for Selected Outpatient Clinic Folder Entries End of the navigation path .