Introduction:
Doctors / Nurses need to note a lot of details in an Encounter by asking
questions in a structured way as well as by taking a number of objective
readings like Pulse, BP, weight. These Subjective / Objective Observations
/ readings are loosely referred to as Tests in Prognocis. They should
not be confused with the Lab Tests.
These Tests have been grouped in to
Vitals
HPI
ROS
Physical
Specialty
Social History
Surgery Forms
The application provides the flexibility to define a set of tests in each
of the above categories, so that the nomenclature, type of response expected,
grouping, can be customized to the Clinic style of working. The fields
used in this screen namely Remarks, Abn flag (Abnormal) and Notes are
optional. User can select which of them should appear on the screen for
each type of test by making appropriate settings in the property, Applicable
Test Fields > applicable.test.fields.VT/HP/RS/PH/SC/SH.
Template: The pre-defined list of doctors
personal templates and clinic level templates are listed here. A super
template is a union of all templates associated with selected complaints.
A click on this label takes the user to the template configuration screen.
This is available only if the property Applicable
Test Dynamic Edit > edit.test.template.VT/HP...
is set to Y. The modified template becomes effective after Save
/ Reset.
"Copy" Button: Before entering
any test results it is possible to copy the test results from the Patient's
previous encounter by clicking on this button. Once the test results are
saved this button is hidden. This feature is available for all the test
types depending upon the settings in property, Applicable
Test Copy > applicable.test.copy.VT/HP/RS/PH/SC/SH.
Some settings also provide to copy these details automatically on creation
of the encounter and save them. This way the Doctor needs to enter only
that which has changed. By default Social History and Specialty are set
for automatic copy in property, Applicable
Test Copy > applicable.test.copy.SC/SH.
Systems: On selecting the template, all
applicable organ / body systems are displayed on the Left Hand Side. Click
on anyone and see the applicable tests displayed on the Right Hand Side.
The selected System has a different background color.
Test / Elements / Symptoms: Once a particular
template is selected and the user clicks on a body system, the tests defined
in that template under the selected body system and applicable to the
sex of the patient are displayed. Whether all the test checkboxes will
be checked by default is controlled by property, Applicable
Tests Checked > applicable.test.checked.VT/HP/RS/PH/SC/SH.
Uncheck the box if the test is not important and not to be executed in
the current Encounter. A test cannot be unchecked if it is marked as mandatory
in the template. User can double click on the test name to invoke the
test master editing screen. This feature is enabled only if the property
Applicable Test Dynamic Edit > edit.test.master.VT/HP...
is set to Y. The modified test becomes effective after Save /
Reset.
Results: The result for each test is entered
against it. The system validates the values based on the definition of
the test in the test master.
Boolean Radio button to choose between two states
Denies / Reports, Yes / No.
Text User can enter any text
Integer User can enter a number without fractions
Fraction User can enter a number with 6 digits
before decimal point and two digits after it.
List Box Select an option from the List Box
Multi Selection Shown with a multi selection
icon
to pop up a predefined set of values from which the user can select one
or more. If values A, B, C are selected the result edit control will display
them as A, B and C. The program inserts the comma and "and"
properly.
Date Shown with an edit control and a Calendar
Icon to select date.
Notes Shown with an edit control and a button
to pop up a bigger multi line edit control for easy editing / viewing.
Zoom: If the Result type is boolean or
list box, there is a provision to zoom to a set of questions depending
on the result entered. (These branches are defined in the Test Master)
The system also supports nested zooming. While printing the progress notes,
the details of the zoom level get printed in a nested fashion. If a zoom
is appiclable for an answer,
this button will be displayed. If the user has nested to a deeper level
of questions, the path is shown on the first row. Each of the levels in
the path are separated with a slash and the paths hyperlinked. Click on
this path to backtrack to the starting screen.
Remarks: This field can be used to explain
any test condition especially abnormal result.
Button: This button pops up a search list to select one or more
abnormal condition remarks as applicable to the test on that row. The
selected text will be concatenated to the remarks column. It is possible
for the user to add new text on the fly while in the search list.
N/Abn: This checkbox indicates if the
result is normal / abnormal. This flag help to generate a Short report
of Only Tests with Abnormal readings. This flag is Auto Generated based
on the following logic:
Test Result Type |
Abnormal If |
Numeric |
Reading Out of Range |
Fraction |
Reading Out of Range |
Boolean |
Second selection |
Set of Values |
Option other than First in List Box |
Text |
- |
Date |
- |
Notes |
- |
The Doctor has an option to over ride this generated flag.
Notes: A place to enter notes in multiple
lines. A button
has been provided to view / edit notes in a larger area in a new pop up.
Note that the phrases used will be popped up relevant to the complaint selected
in HPI and relevant to the template selected in specialty.
Impact of Selecting another Template: Consider
that a Template A has tests T1, T2, T3 and Template B has tests T2, T3,
T4. First select Template A and enter results for T1, T2, T3 and save. Come
back to this screen, the default template will be A. Now select Template
B. Tests T2, T3, T4 will be displayed. Since T4 was not part of the saved
data, Test T4 will be shown as unchecked (Not selected). Since T2 &
T3 had some results saved (although under Template A), the saved results
will be available by default. If this is saved, the results of Test T1,
(which are no longer relevant in Template B) will be deleted and lost from
the database. |