DOCTOR OPD CLINIC KEY-USER MANUAL

KEY-USER MANUAL: DOCTOR OPD CLINIC

PROJECT NAME / CODE:	DEPARTMENT / SERVICE UNIT NAME:		VENUE / LOCATION:
MedCubes Demo	Doctor Full Access		MedCubes Demo HOSPITAL

WORKFLOW DESCRIPTION STEPS MedCubes		ADDITIONAL INFORMATION
1. View patient in patients’ work list 2. Enter Clinical Notes/EMR 3. Ordering · Lab · X-ray · Physio · Dialysis 4. View Result 5. Diagnosis 6. Drug Prescription - OPD 7. Writing Letter 8. Enter Charges 9. Generate and Print Visit Summary 10. Discharge
General Information / support documentation(please select by mouse click): 1. How to get started with KCIS 2 1.1. How to start MedCubes and login to the system? 1.2. How to change the password? 1.3. How to lock the screen when leaving workstation? 2. Some basic hints how to use KCIS 2 2.1. User Interface description 2.2. How to search for data within an app? 2.3. How to zoom an app? 2.4. How to change desktops?

KEY-USER WORKFLOW MANUAL: Doctor OPD Clinic

KEY-USER MANUAL DESCRIPTION - Desktop: DID (WorkFlow)

1. Dashboard Doctor page

The Dashboard Doctor page provides several functions to process Xray, Lab or A&E orders, to enter diagnosis and procedures, record clinical notes and review vital signs of the selected patient.

The Order Monitor / Work List app provides a list of patients assigned to the doctors as well as its related order services for the respective patient. In addition also all Lab analysis can be seen.

1.1 Functions: Patient Details app

Search for and select a Patient.

1.2 Functions: Medical Information buttons

Opens the Allergy app to review and/or enter allergies to the patient.

Opens the Infection app to review and/or enter infections to the patient.

Opens the Diagnosis app to review and/or enter diagnosis (ICD-10).

Opens the Service app to review and/or enter service or procedures.

Opens the Vaccination sheet to review and/or enter immunisations of the patient.

Opens the Free Text Diagnosis enter screen to review and/or enter free text diagnosis of the patient.

1.3. Information buttons

	Display patient’s gender information.
	Displays patient’s blood group information; if available.
	Displays the patient’s VIP status -> turns red when patient is VIP!
	Opens the A&E Triage screen to review for doctors.

1.3 Functions: Orders buttons

	Opens the Order entry dialog with pre-defined DID Service Unit code: RAD
	Opens the Order entry dialog to request consultations.
	Opens the Order entry dialog with pre-defined Laboratory Service Unit code: LAB
	Opens the Order entry dialog with pre-defined A&E Service Unit code: A&E
	Opens the Order entry dialog with pre-defined Special Diagnostics Service Unit code: SPD
	Opens the Order entry dialog with pre-defined Physio/Rehab Service Unit code: REHAB
	Opens the Order entry dialog with pre-defined Oncology Service Unit code: ONCO
	Opens the Order entry dialog with pre-defined Hemodialysis Service Unit code: HMD
	Opens the PACS viewer.
	Opens the EMRA Archive system.
	Opens Patient’s order/request list to display all patient requests for current case.

1.4. Functions: Order Monitor / Work List

	Allows you adjust the app display by using different filter settings.
	Edit the selected order.
	Cancel the selected order..
	Complete (= set to OK) the selected order.
	Refresh app.

1.5 Functions: Service Requested with Order app

	Complete selected order service.
	Complete all order services.
	Cancel selected order service.
	Refresh app.

1.6 Functions: Lab Analysis Overview app

	Cancel selected lab analysis.
	Refresh app.

1.7 Functions: Patient Notes buttons

	Opens the General Notes entry dialog to enter patient notes.
	Opens the Chief Complaints entry dialog to enter patient notes.
	Opens the Examination entry dialog to enter patient notes.
	Opens the Plan entry dialog to enter patient notes.
	Opens the Assessment entry dialog to enter patient notes.
	Opens the Past Medical / Surgical History entry dialog to enter patient notes.

1.7 Functions: Vital Sign app

	Add vital signs.
	Refresh app.

1.7 Support documentation/videos:

· How to enter allergies and infections?

· How to enter diagnosis?

· How to enter free text diagnosis?

· How to enter services and how to filter the service app?

· How create Xray order request?

· How create Lab order request?

· How to request consultations?

· How to complete a request?

· How to add vital signs?

· How to enter clinical notes?

2. Prescription OPD page:

The Prescription OPD page provides all required drug related features and functions.

The upper area buttons displays information (allergies, infections, drug warnings, report notes) as well as allows you to enter and/or review charges. The Prescription app displays all prescription information, below the Pharmacy Overview displays the pharmacy dispensing process of the selected patient and OPD drug prescription.

2.1. Functions: PatientDetails app

Search for and select a Patient.

2.2. Functions: Information buttons

	Opens the Allergy app to review and/or enter allergies to the patient.
	Opens the Infection app to review and/or enter infections to the patient.
	Opens the MIMS Warning app to review drug warnings.
	Opens the Diagnosis app to review and/or enter diagnosis (ICD-10).
	Opens the Charge dialog where you can enter charges based on the patient’s visit.
	Opens the Free Text Diagnosis enter screen to review and/or enter free text diagnosis of the patient.
	Opens the Report Notes app to review and/or enter notes to the selected patient.

2.3. Functions: Prescription app

	Opens the Prescription dialog to enter the prescription to the selected patient.
	Edit selected prescription data.
	Delete selected prescription data.
	Manual check on drug interaction of the patient.
	Opens the drug monograph of the selected drug.
	Saves the prescription and sends the date to pharmacy.
	Cancels unsaved prescriptions.
	Refresh app.

2.4 Support documentation/videos:

· How to prescribe a drug?

· How to edit a prescription?

· How to delete a prescription?

· How to select syntax via dialog?

· How to mix drugs?

· How to trigger MIMS interaction manually?

3. Service page:

The Service page provides details to the selected patient services for the selected case.

The Service Expert button allows you to enter services or procedures. The Diagnosis button indicates patient diagnosis of the current visit.

The Enter Charges buttons allows you to enter pre-defined charges (services) based on visit types. The Allergy button indicates patient allergies.

The lower section displays services / procedures based on defined service type filter settings.

3.1. Functions: Patient Details app

Opens the Patient Search dialog.

3.2. Functions: Services Expert / Diagnosis / Enter Charges / Allergies buttons

	Enter services or procedures.
	Enter pre-defined services based on visits.

3.3. Information buttons

	Display patient’s gender information.
	Displays patient’s blood group information; if available.
	Displays the patient’s VIP status -> turns red when patient is VIP!

3.4. Functions: Radiology/Laboratory / Consultation Fees/Charges / Therapy Services / Other Procedures/Services apps

	Displays a dialog for variable price procedures / services.
	Refresh app.

3.5. Support documentation/videos:

· How to enter patient services?

· How to enter charges?

4. Case Notes page:

The Case Notes page provides a clinical documentation overview of the current case/visit/episode such as xray and lab results, report notes and patient diagnosis. Here several possibilities to document (i.e. attach files) and write clinical notes to the selected patient are available.

4.1. Functions: Patient Details app

Search for and select a Patient.

4.2. Functions: Write Clinical Notes buttons

	Opens the Examination entry dialog to enter patient notes.
	Opens the Chief Complaints entry dialog to enter patient notes.
	Opens the Plan entry dialog to enter patient notes.
	Opens the General Notes entry dialog to enter patient notes.
	Opens the Assessment entry dialog to enter patient notes.
	Opens the Medical / Surgical History entry dialog to enter patient notes.

4.3. Information buttons

	Opens the allergy app with color and number indicator.
	Diagnosis display with color and number indicator.
	Displays patient’s blood group information; if available.
	Display patient’s gender information.
	Displays the patient’s VIP status -> turns red when patient is VIP!

4.4. Functions: Case Documents app

	Add a new document / file.
	Edit document header information.
	Modify text information.
	Delete selected document / file.
	Open / Display selected document /file.
	Search for documents / files.
	Refresh app.

4.5. Functions: Review Case Notes app

Refresh app.

4.6. Functions: Case Diagnosis app

	Open the Add/Edit diagnosis dialog.
	Edit the selected diagnosis.
	Delete the selected diagnosis.
	Finalize all diagnoses.
	Un-finalize all diagnoses.
	Set the selected diagnosis as the main diagnosis.
	Refresh app.

4.7. Support documentation/videos:

· How to add documents / files?

5. Patient Notes page:

The Patient Notes page provides a clinical documentation overview of the current patient. Here all xray and lab results, report notes and patient diagnosis are displayed on MRN basis. This page provides an overall clinical documentation overview of all available cases/visits/episodes; i.e. patient diagnosis, documents and report notes documented during the patient’s medical history.

5.1. Functions: Patient Details app

Search for and select a Patient.

5.2. Patient Information buttons

	Displays patient’s blood group information; if available.
	Display patient’s gender information.
	Displays the patient’s VIP status -> turns red when patient is VIP!
		Opens the Allergy app to review allergies of the patient.
		Opens the Infection app to review infections of the patient.

5.3. Functions: Patient Documents app

	Add a new document / file.
	Edit document header information.
	Modify text information.
	Delete selected document / file.
	Open / Display selected document /file.
	Search for documents / files.
	Refresh app.

5.4. Functions: Patient Diagnosis / Report Notes app

Refresh app.

5.5. Support documentation/videos:

· No support documentation available!

6. Lab page:

The Laboratory page allows you to review lab values of the patient. Here you can view the lab values in long-term view as well to get a trending in a graphical way.

6.1. Functions: Laboratory Values app

Changes the lab value display to a long-term view..

6.2. Functions: Laboratory Chart app

Refresh app.

6.3 Support documentation/videos:

· No support documentation available!

7. Skin page:

The Skin page provides features to documents skin damages and supports a picture display.

7.1. Functions: Skin Protocol app

	Add skin documentation.
	Edit skin documentation
	Delete selected skin documentation
	Refresh app.
	Scroll back and forth between documentations.

7.2. Functions: Assessment app

	Add skin assessment.
	Edit skin assessment.
	Delete selected skin assessment.
	Refresh app.
	Scroll back and forth between assessments.

7.3. Functions: Skin Images app

Refresh app.

7.4. Support documentation/videos:

· How to add skin documentation?

· How to review multiple skin documentations?

8. Eye Exam page:

The Eye Exam page provides features to documents Eye damages and supports a picture display.

8.1. Functions: Eye Assessment Overview app

	Add eye documentation.
	Edit eye documentation
	Delete selected eye documentation
	Refresh app.
	Scroll back and forth between documentations.

8.2. Functions: Eye Assessment details app

	Add eye assessment.
	Edit eye assessment.
	Delete selected eye assessment.
	Refresh app.
	Scroll back and forth between assessments.

8.3. Functions: Image Viewer app

Refresh app.

8.4. Support documentation/videos:

· Same concept as for Skin documentation, please see there!

9. Patient Overview - Doctor page:

The Patient Overview page provides details to the selected patient, his/her employer, next of kin information and current OPD case well as a HITS record list.

9.1. Support documentation/videos:

· No support documentation available!