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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 the Dictate Transcribe screen.

The Dictate Transcribe screen can be invoked from the Patient's Encounter as well as from the menu Patient → Transcribe. 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 is 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 Plan.
  3. Assessment General.
  4. Plan.
  5. Procedures.
  6. Past Medical History (PMH).
  7. Past Surgical History.
  8. Social History.
  9. Family History.
  10. Current Medication.
  11. Health Maintenance.
  12. Personal Notes. (These are for social conversation, and are not part of Progress notes)
  13. Custom Notes 1
  14. Custom Notes 2
  15. Custom Notes 3

The titles for above three options (Custom Notes 1, 2, and 3) 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 displayed as checked. The percentage of the total space used for entering notes is displayed on the right side.