Data Entry Format
i. Predefined selection list/options for writing observation wherever possible.
ii. Presenting complaints in structured format; free writing rich text format (with help of medical dictionary) for history and clinical notes.
iii. Both structured and unstructured examination punching. Easy examination entry using pre-defined option lists.
iv. Easy vital parameters entry form with individual and combined chart.
v. Two formats of ICD diagnosis entry for provisional and final diagnosis. Predefined syndrome list is also possible.
vi. ICD procedure components for procedure.
vii. SOAP analysis for problem analysis.
viii. Special diagnosis formats (e.g. Obstetrics format contains separate values for GPAL EDD, LMP, Gestation, Presentation etc).
ix. Medicines can be prescribed in both generic and brand names. The data to be punched are route of administration, medicine name, unit dose, frequency and duration. Medication status can be active or hold or discontinued; only active medicines are allowed for dosing.
x. Start and close button for IV dosing with rate of infusion.
xi. Start and close button for equipment use, event timings.
xii. Online request for Laboratory, Radiology, Blood, Pharmacy.
xiii. Advance planning for Procedures, Consultations and PO intake.
xiv. Set monitoring and discharge parameters.
xv. Data entry for demographics, images/DICOM, minor procedures, equipment use, event timings, medication and food
i. Patient report for expenses, symptoms, examinations, Laboratory and radiology, Input/Output, Notes and planning.
ii. Reports with customized components for each encounter or all encounters.
iii. Certificates for Discharge, Birth, Death etc.
iv. Customized patient reports can be created using HTML templates.
v. Reports can be printed, saved to online / offline file server or sent through e mail.
i. Outpatient/ER Form contains minimum variables like chief complaints, clinical findings, history, vitals, drug allergy, diagnosis and planning.
ii. Inpatient form contains all types of data entry formats. Separate clinician and nursing examination lists; different examination lists for different departments.
iii. Procedure form contains timings, equipment use and professionals involved. It also contains examination and clinical notes separately for pre-operative, operative, anesthesia and post operative conditions.
iv. Delivery form contains delivery parameters and new born baby registration parameters. It also contains pre-delivery, On-delivery, post-delivery and baby examinations.
v. Structured examination forms can be created and customized according to data.
vi. Unstructured examination form contains all examination and history taking variables.