Topics Dictate Transcribe Search:  
A user can use the detailed forms in the application as explained for HPI, Physical, ROS, Assessment, and other options. All these provide entry of discrete fields as well as Notes. This has the 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, there is an easier way to begin. Notes for all the major headings can be entered here in one place, making it simpler and faster.

This can also provide a third option to the die-hard conservatives, who would like to remain away from the keyboard and stick to dictation. The user may continue the dictation with one small change: do not dictate a letter or a note; dictate the 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 into which edit control on the Dictate Transcribe screen.

The Dictate Transcribe screen can be invoked from the Patient Encounter as well as from the Patient → Transcribe menu. The screen has been designed to be used in any single mode or a combination of all these modes:
  • Direct keyboard entry into the fields.
  • Entry using the handwriting recognition feature of a 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. Specialty
For each of the above, the settings in the property, Applicable Test Fields > applicable.test.field.VT (and others), decide if the 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. The user has the flexibility to enter 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, they will appear here. Any changes made here will also be reflected there, and vice versa.
  1. Last Lab Review – Review comments on lab tests ordered in the previous encounter, or
    lab tests performed in-house in the 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 Medications.
  11. Health Maintenance.
  12. Personal Notes (these are for social conversation and are not part of the Progress Notes).
  13. Custom Notes 1
  14. Custom Notes 2
  15. Custom Notes 3

The titles for the 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 the encounter; there is very little data that the doctor still needs to dictate. The transcriptionist can listen to the dictated recording and enter the transcription into the system using this feature.

The prefix appended for the "Title" on the Dictate Transcribe screen is:

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

The values for Facesheet Notes are defined in the properties "facesheet.notes.title1", "facesheet.notes.title2", "facesheet.notes.title3", "facesheet.notes.title4", and "facesheet.notes.title5".

The values for User Notes are defined in the properties "user.notes.title1", "user.notes.title2", "user.notes.title3", "user.notes.title4", and "user.notes.title5".

The value for Custom Notes is defined under Settings > My Preferences > Defaults.

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.
If the value of the property notes.show.texteditor.for is set to PH-Physical, then the notes in the Notes section are displayed in HTML text format.