Articles on: EMR

How to create Clinical Items

Clinical items are the smallest building block of a case sheet. Clinical Items are combined to form clinical groups, and groups get combined to form clinical sections. Multiple clinical sections make up the case sheet. Let us see how to create a new clinical item.

1. Go to Tools | Clinical Item Parameters | Item Parameters | In Item Parameters click on Add New- This opens up Item Parameter Detail.

2. In Item Parameter Detail, enter the information in the fields as explained below:

a. Item Name
Enter the name of the Clinical Item. Example: Weight.

b. Unit of Measurement
Select from the dropdown the unit of measurement for the Clinical Item. Example: Unit of measurement of Weight is kg, Blood pressure will be mmHg and so on.

c. Clinical Section
The case sheet comprises of various Clinical sections, such as Chief Complaints, Vitals, Social History, etc. We can link the Item parameter to the relevant clinical section by selecting it from the drop-down, to ensure it is searchable. Example: Weight is linked to the Clinical section Vitals.

d. Type
This decides the kind of control that will be displayed to the user for this Item parameter. Example: Dropdown, Numeric, text, etc.

e. Max Length
This field shows up only when the Item Type** is Numeric. This enables you to restrict the number of digits you will allow the user to enter in the item. Example: Weight can be a maximum of 3 digits, hence Max Length will be set as 3.

f. Applies to Gender
You can make some items appear or disappear automatically based on the gender of the patient. Example: Item could be History of Prostate Cancer, the type being Yes/No. However we only want this item to appear in questionnaires of Male Patients, so we can select Applies to Gender = Male. If we did not set gender to male, this item would appear in the questionnaire for both male and female patients.

g. Track Values in EMR
If this option is checked on the Vitals/Lab Results are tracked and graphed.

h. Reference Range
Defines the normal range for the item parameter based on age group, gender, and the corresponding normal value/reading. If the value exceeds this range and item is part of the Lab/Vitals section, then an abnormal flag will get auto switched on.

Updated on: 06/06/2023

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