A web based Electronic medical Records (Emr) & medical custom supervision system.
The software intended to be produce is an online web based medical custom supervision theory intended to computerize the clinic and provide a seam less integration of its various processes.
Basic Stamp 2 Module
The application should facilitate input, storage, replacement and retrieval of medical facts within a custom and enables interfacing with other data providers face the practice.
The application aims to expedite description keeping processes and enable doctors to retrieve and input inpatient Data, medical Data, diagnosis Reports etc., everywhere and anytime from a Pc. Also the application should provide electronic capabilities for routine tasks connected to clinical data( Such as inpatient Registration, hunt for inpatient Transcription, imaging, Messaging and designate writing, Staging of Cancer, suggestion of Relevant Regimens based upon Staging, as well as a wireless point-of-care explication for Doctors in the test room.
Emr Workflow
Modules Overview:
1. Patient Registration and Appointment Scheduling
Patient will be registered with the theory through a Nurse/ front office / doctor.
2. Patient Demographics
Capture all the inpatient introductory details, such as
o Personal Information
o Correspondence details
o History of the Patient
o Social Background
o Insurance Details
o Family History
o Family medical History
o Allergies and Operations
o Education details
3. Patient Chart
Patient chart includes complaints, diagnosis, vitals, prescribed tests, current medications, drug allergies, past surgeries and clinical reminders details will be displayed. Also inpatient name, sex, age, date of last visit and inpatient connected menu will be displayed. A inpatient connected menu choice includes chart, subjective, plan, order, assessment, others, super bill and mark as seen.
4. Physical Examination
List of items for a New bodily Exam will be displayed and by default general details form will be displayed for capturing the details. New bodily Exam can be made for a inpatient includes general details, eyes, ears, etc details list will be displayed.
5. Review of System
If any Clinical Trials facts available, the physician refers to it along with the drug facts Charts, Lab Reports, Chemo Order generation, Clinical Trials Info.
Review all the former hospitalization, reports before starting the treatment.
6. Diagnosis, Staging and Chemotherapy
The physician uses the proposed software from the point where he diagnoses the inpatient and determines the cancer type. The software will be used from then onwards as under:
o Icd Code Master
o Diagnosis Process based on Icd
o Staging
o Stage Grouping
o Medicine for Chemotherapy
o Chemo Order Generation
o Flow Sheet for Chemo Cycle
Based on all the above inputs the physician diagnoses the inpatient and understands the problem. This leads to determining the Cancer Stage.
In case there has been and Clinical Trials facts the physician refers to it along with the drug facts Charts, Lab Reports, Chemo Order generation, Clinical Trials Info. Based on all this facts the physician writes a designate and doctor's note and enter the relevant details with the charge capture form.
In case the inpatient requires Chemotherapy the physician schedules the next appointment for him with a nurse and the relevant procedures have to be followed.
7. E-Prescription
Displays all former prescriptions (if exists) with date and edit links for a single patient. If no designate exists, i.e., the inpatient is a new inpatient physician will originate a new prescription.
8. Doctor Notes
Doctor can able to enter notes about patient, after bodily testing and diagnosis. And a doctor/nurse can also view the list of all physician notes created for a patient
9. Nurses Notes
List of regimens prescribed to a inpatient by the physician will be displayed to a nurse to settle on regimen for capturing other details. Nurses can provide other treatment apart from regimen treatment by phone.
The nurse initiates the chemotherapy process and maintains a detail of medication and Iv entrance for the patient. This process ends with charge Capture based on Icd Codes and subsequent Scheduling for next appointment.
o Nurse will get the relevant inpatient chart.
o Views the Chemo schedule and description.
o Updates the chemo order sheet and creates the nurses notes.
o Closes the 'chemo day' after the chemo has been completed.
o Views the nurse's report/notes.
o Closes the 'Chemo' after all the chemo days have been closed
10. Laboratory Management
This is used to capture tests facts under special diagnosis. If tests are already prescribed for a inpatient by a doctor, then page will be displayed with existing data and can be captured other new tests otherwise new page will be displayed for input, new prescribed tests will be captured and shown back with captured data.
11. Others
o Demo scheme Codes
o Other Scanned Documents
o Spell checker
o Audit Trail
o Phone Call board
12. Billing Management
The software shall not deal with the billing module and if required shall only have an integration with the existing Billing supervision System
13. Reports
o inpatient Registrations
o inpatient Visits
o Diagnosis-Location
o Diagnosis-Cancer
o physician Visits
The above reports will be presented in a graphical representation (Bar and pie chart) for the respective data captured in the application.
Key Features:
1) Patient Registration & Appointment Scheduling
2) Patient Demographics
3) Patient Chart
4) Physical Examination
5) Review Of Systems
6) Mri
7) Hpi
8) Diagnosis, Cancer Staging and Chemotherapy
9) E-Prescription
10) Doctor Notes
11) Nurses Notes
12) Laboratory Management
13) Others
14) Billing Management
15) Reports
16) Admin Module
1) Patient Registration & Appointment Scheduling:
Patient registration can be done in two ways:
1. Through Appointment Scheduling
2. Registration by visit.
Patient will be registered with the theory through a Nurse/ front office / doctor. If a inpatient booked an appointment on a single date, the front office will have a provision to track the inpatient bodily coming status.
2) Patient Demographics
Capture all the inpatient introductory details, such as
The sub functionalities of this highlight are as follows:
a. Personal details
b. Insurance Details
c. Social history details.
d. Medical history details.
e. Family history details.
f. Family medical history details.
g. Surgical history details.
h. Hospitalization details.
i. Correspondence details.
j. Chief complaint(s) details.
k. Drug allergies details.
l. Current medication(s) details.
m. Discontinued medication(s) details.
n. Vitals details will be captured and can modernize date wise.
o. Women Only - Women connected facts will be captured (like number of
Pregnancies and number of Children born etc). This is exclusively for women only.
p. Hipaa - A provision to upload Hipaa connected docs.
Update existing details.
3) Patient Chart
Patient chart includes complaints, diagnosis, vitals, prescribed tests, current medications, drug allergies, past surgeries and clinical reminders details will be displayed. Also inpatient name, sex, age, date of last visit and inpatient connected menu will be displayed. A inpatient connected menu choice includes chart, subjective, plan, order, assessment, others, super bill and mark as seen.
a. Display inpatient Chart
b. Display, Add and Modify Complaints details
c. Display, Add and Modify diagnosis details
d. Display, Add and Modify Vitals details
e. Display, Add and Modify Prescribed Tests details
f. Display, Add and Modify Current Medications details
g. Display, Add and Modify Drug Allergies details
h. Displaying separate details of a inpatient as a description
i. Display, Add and Modify Past Surgeries details
j. Display, Add and Modify Clinical Reminders details
k. Display, Add and Modify Flow sheet details
l. Display, Add and Modify Template for referral note details
m. Display, Add and Modify Template for letter details
n. Display, Add and Modify Tumor ticket details
o. Display, Add and Modify Pt/Inr details
p. Display, Add and Modify Diagnostic test details
4) Physical Examination
List of items for a New bodily Exam will be displayed and by default general details form will be displayed for capturing the details. New bodily Exam can be made for a inpatient includes general details, eyes, ears, etc details list will be displayed. . bodily Exam Gen Id will be generated.
i. The sub functionalities of this highlight are:
a. General details
b. Central Line details
c. Skin details
d. Head and Face details
e. Eyes details
f. Ears details
g. Nose and Nasopharynx details
h. Neck details
i. Lymph Nodes details
j. Musculoskeletal Details
k. Genitalia
l. Rectal
m. Breast
n. Cardiovascular details
o. Respiratory details
p. Abdomen details
q. Extremities details
r. Neurological details
ii. Display list of report(s) created for a single inpatient date wise
iii. Display personel report.
iv. modernize existing description details.
v. Delete existing report(s) details.
5) Review of System
i. Capture the following details
a. General details
b. Eyes details
c. Cardiovascular details
d. Genitourinary details
e. Musculoskeletal details
f. Skin details
g. Psychiatric details
h. Endocrine details
i. Respiratory details
j. Ear, Nose, Mouth and Throat details
k. Gastrointestinal details
l. Breasts details
m. Neurological details
n. Hematological/Lymphatic details
o. Chest Details
ii. Display list of report(s) created for a single inpatient date wise
iii. Display personel report.
iv. modernize existing description details.
iv. Delete existing report(s) details.
6) Mri Details
i. Capture Mri details
ii. Display list of report(s) created for a single inpatient date wise
iii. Display personel report.
iv. modernize existing description details.
iv. Delete existing report(s) details.
7) Hpi
a. General Hpi or Hpi details and can view past Hpi details date wise.
b. Lung Cancer Hpi details.
c. Colon Hpi details.
d. Breast Hpi details.
8) Diagnosis, Cancer Staging and Chemotherapy
The physician uses the proposed software from the point where he diagnoses the inpatient and determines the cancer type. The software will be used from then onwards as under:
o Icd Code Master
o Diagnosis Process based on Icd
o Staging
o Stage Grouping
o Medicine for Chemotherapy
o Chemo Order Generation
o Flow Sheet for Chemo Cycle
Based on all the above inputs the physician diagnoses the inpatient and understands the problem. This leads to determining the Cancer Stage.
In case there has been any Clinical Trials facts the physician refers to it along with the drug facts Charts, Lab Reports, Chemo Order generation, Clinical Trials Info. Based on all this facts the physician writes a designate and doctor's note and enter the relevant details with the charge capture form.
In case the inpatient requires Chemotherapy the physician schedules the next appointment for him with a nurse and the relevant procedures have to be followed.
a. Doctors can view diagnosis report.
b. Doctors can originate diagnosis by choosing Icd Code and Disease Name.
c. Capture Icd Code, histology details, histological grade and residual tumor
grade details.
d. Define the stage and capture stage details.
e. Doctors can see all the existing regimens.
f. Doctors can originate blank regimen or connected regimens with cancer type or
Icd Code and capture the details of regimen.
9) E-Prescription
Displays all former prescriptions (if exists) with date and edit links for a single patient. If no designate exists, i.e., the physician will originate a new prescription.
a. Doctors can sound tasteless designate list.
b. Doctors can sound tasteless drug(s) list.
c. physician can originate a new designate or originate designate with an
existing tasteless prescription.
d. physician can modernize or delete an existing prescription(s) for a single patient.
e. physician can have a preview, print and fax the entire prescription.
f. physician will have watch of chief complaints, cancer type, stage and current
medication(s) and discontinued medication(s) details at the time of giving a
new designate or updating prescription.
g. physician will have a facility hunt for choosing the drug(s).
10) Doctor Notes
Doctor can able to enter notes about patient, after bodily testing and diagnosis. And a doctor/nurse can also view the list of all physician notes created for a patient
a. Doctors have a facility to view list of physician notes as a description created for a
particular patient.
b. Doctors have a facility to view single physician note created for a single
patient
c. Doctors can modernize exiting physician note created for a single patient.
d. Doctors can delete exiting physician notes created for a single patient.
e. Doctors can originate new note on inpatient last visits containing the details of
Hpi, history and plan.
f. physician can originate a new note with an existing physician note for a single
patient.
g. physician can have facility to hunt referral doctors list and can add them to
doctor note.
h. Displaying separate details of a inpatient as a description
i. along with separate details of a inpatient in a single physician note
j. Modifying separate details of a inpatient in a single physician note
k. Doctor's note can be print and fax.
11) Nurse Notes
List of regimens prescribed to a inpatient by the physician will be displayed to a nurse, to settle on regimen for capturing other details. Nurses can provide other treatment apart from regimen treatment by phone.
The nurse initiates the chemotherapy process and maintains a detail of medication and Iv entrance for the patient. This process ends with charge Capture based on Icd Codes and subsequent Scheduling for next appointment.
1) Clicks on the inpatient Id to get the inpatient chart relevant to the nurse.
2) Views the Chemo schedule and description.
3) Updates the chemo order sheet and creates the nurses notes.
4) Closes the 'chemo day' after the chemo has been completed.
5) Views the nurse's report/notes.
Closes the 'Chemo' after all the chemo days have been closed
a. Nurse can view all the regimens prescribed by the physician to a patient.
b. Nurse can settle on regimen to view treatment schedule for that single
regimen to a patient.
c. Nurse can settle on a day in treatment schedule cycle and required data will be
captured for regimen.
d. Nurse can make a note under Non ChemoMedicine, Chemotherapy, Pump,
Phlebotomy, Antibiotic, Hydration, Hormone Injection, Antiemetics, Laboratory
and Paracentesis.
e. Nurse can close or open a day in a cycle for single regimen.
f. Nurse can close or open a cycle or chemo cycle for single regimen.
g. Nurses can provide non chemo other treatment at hospital or on phone.
h. Nurse can view cycle description to a single regimen for a single patient.
12) Laboratory Management
This is used to capture tests facts under special diagnosis. If tests are already prescribed for a inpatient by a doctor, then page will be displayed with existing data and can be captured other new tests, otherwise new page will be displayed for input, new prescribed tests will be captured and shown back with captured data.
a. Doctors can order In-house or Out-House lab tests under Laboratory, special
Diagnosis, Ct scan, Radiology, Respiratory, Physiotherapy, Nuclear Meds,
Ultrasound and Miscellaneous Orders for a single patient.
b. Doctors can cancel the tests which were ordered previously for a single
patient.
c. Doctors can view pending, completed and seen tests for a single patient.
d. Doctors or Lab person can upload In-house or Out-house tests facts
which were undergone present or past by the patient.
e. Clinical Reminders can be captured, modified and displayed.
f. physician or Lab person can view today's tests by inpatient name or test name.
13) Others:
a. Capture inpatient Other Scanned documents & Modify or Edit inpatient Other Scanned documents
b. Demo scheme Codes - Here the diagnosis connected data will be mapped with the guarnatee agreeing to the given gcodes
c. Capture, Modify and Display inpatient Educational facts on diseases
d. Capture, Modify and Display inpatient Medication log
e. Capture, Modify and Display Pathology
f. Display inpatient diagnosis flow sheet agreeing to the inpatient visits.
g. Capture, Modify and Display Bone marrow biopsy
h. Capture, Modify and Display Phlebotomy
i. Capture, Modify and Display Paracentesis
j. Phone Call board - Where the nurse/front office/doctor can attend and designate a convenient explication to a inpatient through phone call. All these details will be captured.
k. Mark as Seen - physician can mark the inpatient consultation status as seen for the day.
l. Spell Checker - Using this feature, the user can perform the spell check with the connected forms.
m. Audi trail - Captures physician Visits on inpatient along with Ip address, visit time stamp and navigation facts on inpatient records.
14) Billing Management
The theory should provide the billing information, which needs to be integrated with the third party billing software.
Capture the following details
a. Original focus of visit charges
b. custom Guideline Adherence charges.
c. Current Disease State charges.
d. Office services charges.
e. Out inpatient introductory consultation charges.
f. Prolonged services charges.
g. Miscellaneous charges.
h. Non-chemotherapy Injections charges.
i. Chemotherapy Injections charges.
j. Non-chemotherapy drugs charges.
k. Chemo supervision charges.
l. Chemotherapy drugs charges.
m. Laboratory services charges.
n. New Consultation charges.
o. Confirmatory Consultation charges.
p. Crisis division aid charges.
q. introductory Hospital Care charges.
r. introductory observation Care 8 hrs charges.
t. Subsequent Hospital Care charges.
u. Follow up Consultation charges.
v. Chemo drug charges will be automatically added to the super bill.
ii. modernize existing details.
iii. Display super bill for all charges.
Note: The software shall not deal with the billing module and if required shall only have an integration with the existing Billing supervision System. It will facilitate all the required inputs/information to the billing software.
15) Reports
a. Patient Registrations
b. Patient Visits
c. Diagnosis-Location
d. Diagnosis-Cancer
e. Doctor Visits
The above reports will be presented in a graphical representation (Bar and pie chart) for the respective data captured in the application.
16) Admin operate Panel
I. Office Admin details
1. Capture the following details
a. Appointment Type details.
Appointment type details include appointment type and description will be
captured.
b. Clinic details.
Clinic details include clinic name, road line1, road line2, city, state, zip, country,
work phone and other phone will be captured.
c. Pharmacy details.
Pharmacy details include pharmacy name, caress person, address1, address2, zip,
phone1, phone2, email, fax1, fax2, registration id, open time, close time and round
clock will be captured.
d. Holiday details.
Holiday details include holiday name, start date, end date, day, recursive and
creation date will be captured.
e. Employee category details.
Employee category details include Employee category name and remarks will be
captured.
f. Employee scholar details.
Employee scholar details include salutation, title, first name, middle name, last
name, date of birth, sex, ssn, marital status, photograph, address1, address2,
city, state, zip, email, home, work, other phone, cell, username, password, role,
superior and Employee category will be captured.
g. custom Scheduler details.
Custom Scheduler details include clinic name, start time, end time, default interval and custom interval will be captured.
h. Employee Leave/Vacation details.
Leave details include Employee name, from date, to date, start time and end time will be captured.
i. Referral physician details.
Referral physician Details include physician name, hospital name, hospital phone, physician phone and classification will be captured.
j. physician clinic details.
Doctor Clinic details include clinic name, Employee name, from date time, to date time, recursive date, start date, from day time, to day time, recurrent day, end date and closed will be captured.
2. modernize existing details.
3. Delete the existing details
Ii. diagnosis supervision details
1. Capture the following details
a. Residual Tumor Grade details.
b. Histological details.
c. Histological Grade details.
d. Icd Code details.
e. Icd Histology details.
2. modernize existing details.
3. Delete the existing details
Iii. Staging treatment details
1. Capture the following details
a. Chemo drug code details.
b. Antiemetics details.
c. Tnm details.
d. Regimen details.
e. Admin code details.
f. Drug code details.
2. modernize existing details.
3. Delete the existing details
Iv. Orders details
1. Capture the following details
a. Mri Part details.
b. Test details.
2. modernize existing details.
3. Delete the existing details
V. Super Bill details
1. Capture the following details
a. Super Bill Header details.
b. Super Bill Data details.
2. modernize existing details.
3. Delete the existing details
Vi. Flow sheet details
1. Capture the following details
a. Flow sheet details.
2. modernize existing details.
3. Delete the existing details
Vii. Demo Project
1. Capture the following details
a. Section details.
b. Cancer Type details.
c. Gcode details.
d. Icd & Gcode mapping details.
2. modernize existing details.
3. Delete the existing details
regards,
Dr Tom