Visits and clinical notes
A visit is where the clinical work is written down. The doctor records notes, vitals and the diagnosis, then issues the prescription, lab order or referral from the same visit.
What it does
- Visit notes in SOAP form: subjective and objective assessment, diagnosis and treatment plan.
- Vitals recorded per visit, with BMI calculated on the server and charts over time in the doctor's view of the patient.
- Diagnoses typed by the doctor or picked from reusable diagnosis templates.
- Prescriptions printed or downloaded as PDF, with the prescribing doctor set from the signed-in user.
- Lab orders sent as a PDF request to the laboratories the clinic registers.
- Referrals as PDF, with the referring doctor set from the signed-in user.
- A visit report PDF.
- 29 specialty modules that add discipline fields to the visit, for example visual acuity and intraocular pressure in ophthalmology, or a tooth chart in dentistry.
- SOAP notes, vitals, diagnoses and specialty fields are stored encrypted in the database.
How it fits
Each visit sits on the patient record, and its billing lines feed the invoice and the payments. Specialty modules add their own step to the visit.
Related
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