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A User can use the detailed forms in the applications as explained for HPI, Physical, ROS, Assessment and other options. All these provide entry of discreet fields as well as Notes. This has a big advantage of capturing all database fields, making a detailed analysis possible at a later date, and giving more flexibility in generating the progress notes.

However, if this is considered too daunting a task, this is an easier way to begin. Notes for all the major heads can be entered here at one place, making it simpler and faster.

This can also provide a third option to the die hard conservatives, who will like to remain away from the keyboard and stick to dictation. User may continue the dictation with one small change. Do not dictate a letter or a note. Dictate relevant fields. First announce the name of the Patient, call out HPI followed by its details, call out ROS followed by its details and so on. This way the transcriptionist knows what information is to be entered in which edit control on this screen.

This screen can be invoked from the Encounter feature as well as from the Patient > Transcribe menu option. The screen has been designed to be used in any or combination of all these modes:
  • Direct keyboard entry into the field.
  • Entry using handwriting recognition feature of Tablet PC.
  • Entry using Voice to Text software like Dragon.
  • A Transcriptionist listening to a dictation, and entering it. Since PROGNOCIS is fully web enabled, the transcriptionist (even if outsourced) can have remote access using the Internet.
Fields available for recording:
  1. Vitals
  2. HPI – Each complaint
  3. HPI - General
  4. ROS – Review of Systems
  5. Physical
  6. Speciality
For each of the above, the settings in the property, Applicable Test Fields > applicable.test.field.VT (and others) , decide if Notes field in applicable. If it is applicable, the corresponding row will appear in the table here.

Usually, a nurse enters the list of complaints, and each complaint appears in the table here. User has flexibility to enter the notes for each complaint. If preferred choose to have only one consolidated HPI note without individual complaints.

If any Notes are entered on any other screen during the present encounter, the same will appear here. Any changes made here will also get reflected vice versa.
  1. Last Lab Review – Review comments on Lab test ordered in previous encounter, or
    Lab test performed in-house, in current encounter.
  2. Assessment Notes.
  3. Plan.
  4. Procedures.
  5. PMH, Past Medical History.
  6. Social History.
  7. Current Medication.
  8. Personal Notes. (These are for social conversation, and are not part of Progress notes)
  9. Custom Notes 1
  10. Custom Notes 2
  11. Custom Notes 3

The titles for above three options can be defined for each Doctor as part of My Preferences > Test Templates > Defaults. Notes can be maintained for each of them.

Most of the Patient details are captured live during his encounter, there is very little data which the doctor can still continue to dictate. The transcriptionist can listen to the dictated recording and enter the transcription in the system using this feature.

The prefix appended for the ‘Title' on screen Dictate Transcribe are:

  1. For Facesheet Notes: FS Note
  2. For User Notes: User Note and
  3. For Custom Notes: AttDoc

The value of Facesheet Notes is defined in the properties ‘ facesheet.notes.title1 ', ‘ facesheet.notes.title2 ', ‘ facesheet.notes.title3 ', ‘ facesheet.notes.title4 ', ‘ facesheet.notes.title5 '.

The value of User Notes is defined in the properties ‘ user.notes.title1 ', ‘ user.notes.title2 ', ‘ user.notes.title3 ', ‘ user.notes.title4 ', ‘ user.notes.title5 '.

The value of Custom Notes is defined under Settings > My Preferences > Default .


Notes: All the options for which notes have been entered are checked. The percentage of the total space used for entering notes is displayed on the right side.

History of Present Illness: The application has an elaborate option to display a detailed questionnaire and accept the results / answers. This can be popped up during the encounter. In case the Doctor finds it difficult to enter the details, he can ignore the questions and instead dictate his brief. This can be entered in this field.

Previous Lab Result: In case the patient has been to some Lab and brought his result, the doctor may want to dictate the summary of findings. This will be required only for the first visit of the patient. There after, the system is capable of printing the details of previous encounter Lab Order results, since they will be entered as part of the application.

Assessment: This is indeed the most important observation / conclusion made by the doctor. The pop up in the encounter allows the doctor to enter the relevant ICD Codes and CPT Codes, which are mandatory besides the assessment notes. While he has to select the ICD / CPT Codes, he may take the liberty of dictating the assessment notes. In which case the dictated notes can be entered in this field.

Plan Other Comments & Plan Procedures discussed:
After assessing the problem, the Doctor has a Plan. This involves making Lab / Radiology Orders, Prescribing medicines. These are entered and ordered online. Besides this the Doctor can suggest / recommend procedures or make other comments / suggestions. These are just descriptive notes, which the doctor can enter, on-line or prefer to dictate. Enter the dictated notes here.

When these fields are entered, an Alert is automatically send to the Attending Doctor by the system. He is expected to view this transcript and click on the Approve button. Once this is done the details cannot be modified and the encounter is considered as frozen.
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