Managing your Patient’s Encounter

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Records Management – Current Encounter – Encounter Tab

NOTE: The Current Encounter pertains to the present or on-going interaction that the patient is undergoing with respect to the Medical Records Module users. It contains every piece of information that is useful to the betterment of the patient’s health. 

Steps to Manage Encounter

  1. In the Current Encounter > Encounter tab
    • Input the patient’s chief complaint or the main reason for their visit. 
    • Input HPI or History of Present Illness.
  1. To update Medical History section:
    • Input Past Medical History, Family History, Social History, Allergies History, Birth History, Gynecological History, Hospitalization History, Immunization/Vaccination History, Menstrual History,  Obstetric History, Surgery History, and Dental History. 
      1. Click “Add New”
      2. Enter the necessary details.
      3. Click “Save Records”.
NOTE: These fields can be set to enabled or disabled in the Administrative module, specifically Settings > Medical Records > Record Fields. 
NOTE: Next is the Review of Systems wherein users can input the patient’s current status per organ. The system also provides an option for general findings which can be accessed through the catalogue icon on the right side of the text field. 
NOTE: Users will find next the section for Vitals wherein they can input the patient’s vital signs upon check up. This section also includes Visual Acuity. 
  1. To fill out the patient’s Vitals:
    1. Select a field
    2. Type the necessary details.
    3. Click “Save Records” to finalize.
NOTE: The Specialty Features pertain to the features unique to the specialty of the doctor such as ENT and Obgyne.
  1. To fill out the specialty features:
    • Click the “Add New” button.
    • Fill out the the needed details.
    • Click “Save Records” to finalize.
NOTE: In the Physical Exam section, users can input their findings about the patient’s physical examination. 
  1. To fill out the Physical Exam section:
    • Click the button that corresponds to the body part or organ,
    • A section for that specific body part/organ will appear on the text field. 
    • Input the findings respectively.
    • Select Level of Consciousness and Pain Assessment. 
    • Click “Save Records” to finalize. 
NOTE: Next is the Impression section where users can put their initial impression about the patient’s medical condition as well as the date of when the impression was made. 
NOTE: The Diagnosis section provides a text field for the medical condition diagnosis of the patient. The system also provides a list of ICD10 or the International Statistical Classification of Diseases in its 10th revision issued by the World Health Organization which will help users, specially doctors to classify and code their diagnosis. Users can also select the recommended procedures which the clinic provides that patients should take. 

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