Hello there! This tutorial will teach you how to create your patients’ charting using MYCURE. Let’s start by choosing a patient.
Patients (EMR) > Medical Records > Select patient
Tap on Charting (yellow button). This is where you will view the list of charting records you have previously created. To add a new entry, tap NEW.
MYCURE follows SOAP methodology for ease of flow.
For Subjective, there are 3 main contents: Date of record, chief complaint, and History of Present Illness (HPI).
The date of record can be altered based on when the original record was created. This is useful especially when you are transferring paper records into electronic records through MYCURE. It’s also useful if you are still adjusting to the technology and cannot use it in real time yet. Some of our users prefer uploading the records in the evening or a few days after. It’s completely fine, so long as you get the details right.
For the chief complaint, you can type or select from our list of symptoms, or simply tap on the text field to type your chief complaint and HPI.
For Objective, we have 3 categories: Vitals, Exams, and Attachments.
Vitals – record the patient’s general to specific vital signs
In Exams, you can make physical assessments such as level of consciousness, pain assessment and physical exam.
In Attachments, draw over medical illustration templates to take graphic notes. You can also take pictures or attach images related to the encounter.
For Assessment, you indicate your diagnosis here. You can type or select from the ICD-10 database provided. A summary of the subjective and objective information are also placed here for reference.
Lastly for Plan, this is where you indicate the care plan notes and link other documents such as prescriptions, lab test orders, and other medical medical forms.
To preview the complete chart, simply tap “PREVIEW” on the upper-right corner.
If you wish to edit, tap “X” to go back. And if you are done, tap “CREATE” to finalize the record.