Component documentationPatient Record

 

The patient record provides an overview of the central information on a patient. From the patient record, you can view and edit patient-specific information such as diagnoses, services and findings, and create new objects.

Example Example

For medical rounds you require the patient's most recent findings so that you know how the values of the patient have changed since the last rounds.

You compile a long-term overview for a patient, from which you can determine whether and when the patient has already been treated in the hospital and which diagnoses were made within the hospital stays.

End of the example.

Note Note

You can use the patient record for all institutions for patients with patient master data. It is not available to you for patients with provisional patient master data.

End of the note.

Integration

The patient record is integrated into the patient profile. You can find information under Patient Profile.

In order to be able to use the patient record, you must have made corresponding settings in Customizing of the patient record. You can find information on this under Setup Functions for the Patient Record.

Features

User Interface Building Blocks (UIBBs) are available for displaying objects (for example, documents) in the patient record. The UIBBs enable the flexible arrangement of the information, which you can easily adapt to the various situations in the medical treatment.

The display of the UIBBs in the patient record is different depending on the configuration of the display in Customizing of the patient profile, and the assignment of the configuration to a user or a role. For information about this, see Configuration Functions for Patient Profile.

The system provides the following UIBBs in the patient record as standard:

  • Smart Chart

  • Vital Signs

  • Lab Values

  • Medication Orders

  • Documents

  • Examinations

  • Diagnoses

  • Progress Report

  • Services

  • Indicators

Within the UIBBs, you can use the following functions:

  • You can display information.

  • You can edit objects with one-click actions.

  • You can create new objects.

  • You can call the patient data in fullscreen mode.

  • You can use filter functions to filter the displayed objects according to various criteria.

  • You can use an indicator to flag objects for tracking.

    The system displays the flagged objects in the Indicators UIBB, which displays all flagged objects, regardless of the case/time period selection.

Business Add-Ins (BAdI) are also available, with which you can customer-specifically adapt the patient record according to your requirements. You can find information on this under Customer-Specific Enhancements for the Patient Record.

Caution Caution

In customer programs to create paper printouts or PDF files, the assignment of data (patient name, contents, details, status, and so on) between screen presentation and printout or within the printout needs to be unique and correct.

Users are accustomed to WYSIWYG when printing from many SW programs. If the printout does not match the displayed or stored information, procedures required for diagnostic and therapeutic purposes could be delayed or inappropriate procedures planned and performed. This could lead to the endangerment of patients.

When implementing print functions, ensure clean programming code so as to keep to the WYSIWYG principle as far as possible. This is especially important if the external appearance of the printout is very different from what is on screen, since plausibility checks by users have little success here.

End of the caution.