A web based Electronic healing Records (Emr) & healing custom management system.
The software intended to be build is an online web based healing custom management ideas intended to computerize the clinic and furnish a seam less integration of its assorted processes.
Basic Stamp 2 Module
The application should facilitate input, storage, change and retrieval of healing information within a custom and enables interfacing with other data providers covering the practice.
The application aims to expedite description retention processes and enable doctors to retrieve and input patient Data, healing Data, prognosis Reports etc., in any place and anytime from a Pc. Also the application should furnish electronic capabilities for habit tasks related to clinical data( Such as patient Registration, hunt for patient Transcription, imaging, Messaging and prescribe writing, Staging of Cancer, recommendation of Relevant Regimens based upon Staging, as well as a wireless point-of-care solution for Doctors in the exam room.
Emr Workflow
Modules Overview:
1. Patient Registration and Appointment Scheduling
Patient will be registered with the ideas straight through a Nurse/ front office / doctor.
2. Patient Demographics
Capture all the patient 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 healing 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 patient name, sex, age, date of last visit and patient related menu will be displayed. A patient related 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 patient includes general details, eyes, ears, etc details list will be displayed.
5. Review of System
If any Clinical Trials information available, the physician refers to it along with the drug information Charts, Lab Reports, Chemo Order generation, Clinical Trials Info.
Review all the previous hospitalization, reports before starting the treatment.
6. Diagnosis, Staging and Chemotherapy
The physician uses the proposed software from the point where he diagnoses the patient 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 patient and understands the problem. This leads to determining the Cancer Stage.
In case there has been and Clinical Trials information the physician refers to it along with the drug information Charts, Lab Reports, Chemo Order generation, Clinical Trials Info. Based on all this information the physician writes a prescribe and doctor's note and enter the relevant details with the fee capture form.
In case the patient 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 previous prescriptions (if exists) with date and edit links for a particular patient. If no prescribe exists, i.e., the patient is a new patient 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 patient by the physician will be displayed to a nurse to go for regimen for capturing other details. Nurses can furnish other rehabilitation apart from regimen rehabilitation by phone.
The nurse initiates the chemotherapy process and maintains a information of medication and Iv way for the patient. This process ends with fee Capture based on Icd Codes and subsequent Scheduling for next appointment.
o Nurse will get the relevant patient chart.
o Views the Chemo program 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 information under extra diagnosis. If tests are already prescribed for a patient 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 project 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 management System
13. Reports
o patient Registrations
o patient 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 ideas straight through a Nurse/ front office / doctor. If a patient booked an appointment on a particular date, the front office will have a provision to track the patient bodily coming status.
2) Patient Demographics
Capture all the patient introductory details, such as
The sub functionalities of this feature are as follows:
a. Personal details
b. Insurance Details
c. Social history details.
d. Medical history details.
e. Family history details.
f. Family healing 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 update date wise.
o. Women Only - Women related information 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 related 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 patient name, sex, age, date of last visit and patient related menu will be displayed. A patient related menu choice includes chart, subjective, plan, order, assessment, others, super bill and mark as seen.
a. Display patient Chart
b. Display, Add and Modify Complaints details
c. Display, Add and Modify prognosis 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 different details of a patient 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 marker 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 patient includes general details, eyes, ears, etc details list will be displayed. . bodily Exam Gen Id will be generated.
i. The sub functionalities of this feature 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 particular patient date wise
iii. Display private report.
iv. update 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 particular patient date wise
iii. Display private report.
iv. update 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 particular patient date wise
iii. Display private report.
iv. update 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 patient 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 patient and understands the problem. This leads to determining the Cancer Stage.
In case there has been any Clinical Trials information the physician refers to it along with the drug information Charts, Lab Reports, Chemo Order generation, Clinical Trials Info. Based on all this information the physician writes a prescribe and doctor's note and enter the relevant details with the fee capture form.
In case the patient 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 prognosis report.
b. Doctors can originate prognosis 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 related regimens with cancer type or
Icd Code and capture the details of regimen.
9) E-Prescription
Displays all previous prescriptions (if exists) with date and edit links for a particular patient. If no prescribe exists, i.e., the physician will originate a new prescription.
a. Doctors can say coarse prescribe list.
b. Doctors can say coarse drug(s) list.
c. physician can originate a new prescribe or originate prescribe with an
existing coarse prescription.
d. physician can update or delete an existing prescription(s) for a particular patient.
e. physician can have a preview, print and fax the whole prescription.
f. physician will have note of chief complaints, cancer type, stage and current
medication(s) and discontinued medication(s) details at the time of giving a
new prescribe or updating prescription.
g. physician will have a installation 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 installation to view list of physician notes as a description created for a
particular patient.
b. Doctors have a installation to view particular physician note created for a particular
patient
c. Doctors can update exiting physician note created for a particular patient.
d. Doctors can delete exiting physician notes created for a particular patient.
e. Doctors can originate new note on patient last visits containing the details of
Hpi, history and plan.
f. physician can originate a new note with an existing physician note for a particular
patient.
g. physician can have installation to hunt referral doctors list and can add them to
doctor note.
h. Displaying different details of a patient as a description
i. along with different details of a patient in a particular physician note
j. Modifying different details of a patient in a particular physician note
k. Doctor's note can be print and fax.
11) Nurse Notes
List of regimens prescribed to a patient by the physician will be displayed to a nurse, to go for regimen for capturing other details. Nurses can furnish other rehabilitation apart from regimen rehabilitation by phone.
The nurse initiates the chemotherapy process and maintains a information of medication and Iv way for the patient. This process ends with fee Capture based on Icd Codes and subsequent Scheduling for next appointment.
1) Clicks on the patient Id to get the patient chart relevant to the nurse.
2) Views the Chemo program 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 go for regimen to view rehabilitation program for that particular
regimen to a patient.
c. Nurse can go for a day in rehabilitation program 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 particular regimen.
f. Nurse can close or open a cycle or chemo cycle for particular regimen.
g. Nurses can furnish non chemo other rehabilitation at hospital or on phone.
h. Nurse can view cycle description to a particular regimen for a particular patient.
12) Laboratory Management
This is used to capture tests information under extra diagnosis. If tests are already prescribed for a patient 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, extra
Diagnosis, Ct scan, Radiology, Respiratory, Physiotherapy, Nuclear Meds,
Ultrasound and Miscellaneous Orders for a particular patient.
b. Doctors can cancel the tests which were ordered previously for a particular
patient.
c. Doctors can view pending, completed and seen tests for a particular patient.
d. Doctors or Lab person can upload In-house or Out-house tests information
which were undergone gift 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 patient name or test name.
13) Others:
a. Capture patient Other Scanned documents & Modify or Edit patient Other Scanned documents
b. Demo project Codes - Here the prognosis related data will be mapped with the insurance according to the given gcodes
c. Capture, Modify and Display patient Educational information on diseases
d. Capture, Modify and Display patient Medication log
e. Capture, Modify and Display Pathology
f. Display patient prognosis flow sheet according to the patient 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 prescribe a convenient solution to a patient straight through phone call. All these details will be captured.
k. Mark as Seen - physician can mark the patient consultation status as seen for the day.
l. Spell Checker - Using this feature, the user can achieve the spell check with the related forms.
m. Audi trail - Captures physician Visits on patient along with Ip address, visit time stamp and pilotage information on patient records.
14) Billing Management
The ideas should furnish the billing information, which needs to be integrated with the third party billing software.
Capture the following details
a. Customary focus of visit charges
b. custom Guideline Adherence charges.
c. Current Disease State charges.
d. Office services charges.
e. Out patient 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 management charges.
l. Chemotherapy drugs charges.
m. Laboratory services charges.
n. New Consultation charges.
o. Confirmatory Consultation charges.
p. Urgency division aid charges.
q. introductory Hospital Care charges.
r. introductory observation Care 8 hrs charges.
t. Subsequent Hospital Care charges.
u. Effect up Consultation charges.
v. Chemo drug charges will be automatically added to the super bill.
ii. update 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 management 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, street line1, street line2, city, state, zip, country,
work phone and other phone will be captured.
c. Pharmacy details.
Pharmacy details include pharmacy name, touch 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. Laborer class details.
Employee class details include Laborer class name and remarks will be
captured.
f. Laborer expert details.
Employee expert 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 Laborer class 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. Laborer Leave/Vacation details.
Leave details include Laborer 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, Laborer name, from date time, to date time, recursive date, start date, from day time, to day time, recurrent day, end date and complete will be captured.
2. update existing details.
3. Delete the existing details
Ii. prognosis management 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. update existing details.
3. Delete the existing details
Iii. Staging rehabilitation 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. update existing details.
3. Delete the existing details
Iv. Orders details
1. Capture the following details
a. Mri Part details.
b. Test details.
2. update 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. update existing details.
3. Delete the existing details
Vi. Flow sheet details
1. Capture the following details
a. Flow sheet details.
2. update 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. update existing details.
3. Delete the existing details
regards,
Dr Tom
Web Based Electronic medical Records & medical practice supervision law
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