HOWTO: Create a New Patient Record v7- Dashboard Links

From OpenEMR Project Wiki

Introduction

Keep in mind that the purpose of this series of pages is to discuss the places in OpenEMR where one may- or should- enter information to create a complete new patient record. It is not to explain all the features and controls displayed on these screens.


Some of the dashboard links give access to repositories of different sorts of patient information (ovals below on the ones that do).

AddNewPt7 16.png


The Links

Dashboard

The line of dashboard links is visible from many other displays of the EMR. This link brings the user back to this Dashboard page from other displays.


History

AddNewPt7 16b.png

  • additional non- demographic patient info
  • Click 'Edit' and go through tabs, adding patient information in the same fashion as with Demographics
  • you may customize the data entry panels in the same fashion as the Demographics LBFs, using the 'History' layout (from main menu: Admin/ Forms/ Layouts'; not pictured)



The Tabs/ Fields:

AddNewPt7 16c.png

General

The Patient’s own health history



Family History

Areas for free text entries of family history with code picker in blanks for optional diagnosis codes.

AddNewPt7 16d.png


Relatives

Free text spaces for the family members (example, ‘Sister’, ‘Father’) who have those conditions

AddNewPt7 16e.png



Lifestyle

Multiple lifestyle habits of the patient and degree of use

AddNewPt7 16f.png


Other

Free-text spaces for additional relevant history

AddNewPt7 16g.png



Report - no new patient data

Documents

  • Files with patient information can be uploaded from a user’s computer to space reserved for that patient in the EMR server.
  • Users may view and annotate those files while in that patient’s record.
  • Content can include image files, scanned hardcopies of patient documents or or other digital files


The structure of the document tree can be customized to the practice needs in 'Practice Settings', though note that the customized structure is used for the entire practice with all patients; it cannot be special- made for individual patients.

See beginning of this wiki page for context and later in page for links to more:

OpenEMR_7_Practice_Settings#Documents


How To Upload Documents To A Patient Record

1. in patient record’s dashboard links click to open 'Documents'

2. in the 'Documents List' window click on the document category you want to upload to. Here using 'Medical Record'

AddNewPt7 19doc02.png



AddNewPt7 19doc03.png


Use controls in top half (rectangle); lower ones are for other activities



3. Click 'Choose Files' - upload dialog opens (appearance varies depending on your browser and Operating System)




AddNewPt7 19doc04.png



4. Select file on local system (not pictured)

  • Selected file now displayed (round rectangle, right)


5. Click blue 'Upload' (oval)



AddNewPt7 19doc05.png



  • Document is now stored in the selected category





Transactions - no new patient data

Issues

AddNewPt7 18Issues01.png

  • default display lists several different types of patient problems or treatment issues, with headings of their start/ stop dates, codes and other information categories.
  • click the blue 'Add' button by each section heading to add an issue of that type
    • or when you do have a list of issues, select the checkbox next to the issue line and click the red 'Delete' to remove it.


Issues entry panel
  • Each issues list has a few controls that are unique to the type of issue, but they will all basically work the same.



While OpenEMR is not specifically designed to use 'Problem Oriented Medical Records' (POMR) this list of issues and problems does allow for something resembling POMR charting. One would use the available mechanism shown below to associate encounters with issues. Formal documentation of POMR in OpenEMR is not written at this time.


Associate Issues with Encounters

Each occurrence of an issue may be associated with particular encounters. In previous image, clicking the 'Edit' opens the dialog where any of the patient's Issues (left column) can be associated with any of their encounters (right column); see the instructions in the dialog. Note that this demo patient has limited encounters and issues.

AddNewPt7 18Issues03.png



The Default Issues

  • Allergies
  • Dental Issues
  • Medical Devices
  • Medical Problems
  • Medications
  • Surgeries


The issues list itself can be edited to suit a practice’s specialized needs. See: HOWTO:_Customize_The_Issue_Types_List



Ledger - no new patient data

External Data

This is a poorly documented feature, but it seems to require patient data imported from a CCDA. See forum post https://community.open-emr.org/t/external-data-in-patient-summary/13271/4



Conclusion

Thus endeth the summary of the data entry process to create a complete new patient record.



Return to previous pages:

HOWTO: Create a New Patient Record v7 - New - Search

HOWTO: Create a New Patient Record - OpenEMR v7 - The Patient Dashboard

Retrieved from "https://www.open-emr.org/wiki/index.php?title=HOWTO:_Create_a_New_Patient_Record_v7-_Dashboard_Links&oldid=36150"