Recording a Patient Visit is the most important and essential feature an EMR solution can provide. Clinicea includes a highly sophisticated EMR module. It is extremely user-friendly, simple, and fully customizable.
Let us have a look at how to record a Patient Visit on Clinicea:
1. Open up a Patient Chart and go over the auto-compiled Medical Summary.
2. Once you have scanned through the Patients Medical Summary, navigate to the left-hand side of the page. Clinicea will point out to the default case sheet. For Example, Admission is the default case sheet here. You can change the case sheet according to your preference.
3. To change the Case Sheet, click on the Case Sheets icon on the top of the page | A Case Sheet section will open on the right | click on Apply beside the Case Sheet you would like to use. For Example, The Case Sheet has been changed from Admission to Consultation 2.
4. Let us stick to our default case sheet, for now, ie Admission. Record the Patient Visit by filling out the relevant Clinical Sections in the case sheet.
If you want to add anything to the existing case sheet, you can do so the clicking the “+” beside the section and a list appears on the right. Choose what you want and click the “+” button to add it to the sheet. Similarly, you can add something new as well if the item is not present in the list.
Clinical Sections in a Case Sheet can be preset and customized according to how you want it. You may not require all of the Clinical Sections mentioned above and you can choose to remove it from the case sheet. (For more info click on How to Build a Case Sheet).
5. Once all clinical sections have been filled out, press Save. If you want to provide your patient with a Prescription, then click on Print. This action also saves the encounter.
6. Once you click on print, you can provide the patient with a Prescription (Print Template set in the selected Case Sheet). A Prescription page opens. The print template already selected for you for the prescription. Simply click on the Print icon to give the printed Prescription to the Patient.
7. Once you have provided the Prescription to the patient and you know that the visit is over, simply click on Check Out Button. This will automatically check the patient out from the appointment screen in the calendar and you have recorded your first Patient Visit.