A medical record is a confidential record that is kept for each patient by a healthcare professional or organisation.
It contains the patient's personal details (such as name, address, date of birth),
A summary of the patient's medical history, and documentation of each event, including symptoms, diagnosis, treatment and outcome.
Relevant documents and correspondence are also included.
History - Medical Record 18/06/10 TO MR PO MR
Ideal Medical Record 18/06/10 Electronic Health Record Womb to tomb Health Record Acute EPR Social Care Direct Walk-In Centres Primary/Community EPR MMR Vaccination Meningitis Vaccination Alzheimer's Divorce Redundancy Depression Panic attacks Suspected cancer Fractured Femur Appendicitis Additional data associated with healthcare event, e.g. referral details, test results etc. Road Traffic Accident
Migrating from Paper to Electronic Data Starting Point “ the way I do it now” Paper “ feels like typing or dictating” Electronic free text “ feels like filling in a form” Partially structured “ feels like picking everything from a huge menu” Rigidly structured
Spectrum of National Health System 18/06/10 Community Visits Out Patients Visits GP/practice nurse Attends A&E Visits a walk-in centre Calls NHS Direct Uses NHS Direct.online Uses the Home Health Care Guide Calls OOH service Attends as in-patient Is visited at home by GP, nurse, care worker, midwife etc Goes to the pharmacy Visits the dentist
18/06/10 EHR EHR Architecture INVESTIGATION REPORTS Blood test Biochemistry Imaging CLINICAL DATA Histories Examination DEMOGRAPHICS NHS Number Name, Address Date of Birth, Sex Registered GP/Contact details HA/EHR identifier Potential ‘Patient URL’ DIAGNOSIS AND TREATMENT DATA
Primary Objective of EHR 18/06/10 Patient Care Legal Management Research Education Audit Decision Support
EHR Architecture 18/06/10 History Examination Investigation Diagnosis Treatment
Levels of EPR
Clinical administrative data
Integrate clinical diagnosis and treatment
Clinical activity support
Clinical knowledge and decision support
Specialty specific support
Advanced multimedia and telemedicine
Lifetime record of medical data
Semi-structured format for usability and usefulness
Backups and archiving
Ad-hoc search, reports and Statistical analysis
Encompasses any specialty or services
18/06/10 The Encounter detail shows the past visit date time and type of visit The screen holds information about the personal details of the patient like Patient NI No, Name, NSH No, Age Sex Place , Referral Doctors name and Diagnosis with treatment details It has search feature, using which the user can access the desired patient’s NI No, NHS No or First name
Appointments 18/06/10 The appointments section opens up the appointments for the current day, for all the doctors registered into the software. The user can book appointments for the patient, with any particular doctor from here. The weekly and monthly appointments can also be viewed.
18/06/10 A new patient can be registered. His/her personal, home, job, and other details can be entered from here. The Encounter detail are entered here
Symptom course 18/06/10 S1 S2 S3 Time
18/06/10 Temporal History Electronic Health Record History 2 History 5 History 3 History 4 History 1
18/06/10 The history of the patient’s present illness are recorded & reflected here. History of present illness can be recorded
18/06/10 There is a dropdown list of the Systems in the body. Selecting a particular System brings up another exhaustive list of Symptoms pertaining only to the System selected.
18/06/10 Symptom details can be recorded in a more formal and structured way for analysis and Decision support
18/06/10 History of the patient’s past illness and family history of illnesses can be recorded here, in order to trace any hereditary illness.
18/06/10 Temporal Examination Electronic Health Record Examination 2 Examination 5 Examination 3 Examination 4 Examination 1
18/06/10 Clinical Examination details can be recorded here. A long exhaustive list of examinations is provided. This would open up another screen, in which questions for the selected examination are asked and the answers are fed into the system. This information is used to generate a calculated report for the same.
18/06/10 Pre-formatted medical examination can be changed with negative findings Body weight and vitals can be entered in structured text for follow up, analysis and trend
Investigation results 18/06/10
Temporal record of Investigation 18/06/10 Electronic Health Record Investigation 2 Investigation 5 Investigation 3 Investigation 4 Investigation 1
Lab tests are divided into Imaging, Biochemistry, Histopathology and hematology.
Selecting appropriate test details can be entered. Images of X-Ray, CT scan, and MRI also can be stored. Video clips of angiogram also can be stored.
Scanned images of test report also can be stored.
Summary of test report with date is shown in the front screen, which can bee arranged chronologically.
The user can select from a list of lab tests to record details.
18/06/10 The relevant screen shows up when the lab test is selected from the list. Details pertaining strictly to the selected lab test are to be filled in by the user.
Disease Course 18/06/10 1 2 3 4 5
Temporal record of Life time Diseases 18/06/10 Electronic Health Record Disease 2 Disease 5 Disease 3 Disease 4 Disease 1
18/06/10 The diagnosis of the patient with date and ICD code is recorded in this screen The Details of Diagnosis con be entered by double clicking on Diagnosis The Functional Status Score of the system can be calculated. Assessment of case is recorded for each visit.
18/06/10 The Functional Status of the patient and different scales are used for follow-up Discussion of the case is entered in this screen with reason for diagnosis and plan for treatment t.
18/06/10 List of drug used for patient are recorded chronologically. Details of prescription is recorded clicking the drug, where start date, end date, dosage, unit, route, frequency, and duration are recorded Effect and side effect of the drug is recorded chronologically
18/06/10 Surgical notes and anesthesia details are also recorded by clicking the Procedure
18/06/10 Anesthesia notes are recorded here
Patient demographic and encounter summary is displayed on the header with patient picture.
This is most useful screen for filling information at one go. Only relevant medical information is displayed, detail is hidden behind.
This screen is useful for follow-up as well as for new patient medical recording.
Emergency Data Medical summary information including diagnosis, symptom, examination, lab test and treatment are displayed
Clicking any screen you can go to the detail screen.
Statistics 18/06/10 Statistics of the Diagnosis, Symptom, and Lab Test are depicted as graphs which enables the doctor to analyze his/her practice.
Mobile EPR 18/06/10
PDA is for mobile medical Record reviewing outside the place of practice.
Summary of medical information is stored here.
The user can synchronize PDA with PC medical record.