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Managing Patient Records (EHR/EMR) in 4Geeks Health¶

Overview¶

The Patient Management module in 4Geeks Health provides secure, comprehensive electronic health records (EHR/EMR) management. From patient demographics to medical history, diagnoses, treatment plans, and coding — everything you need to deliver coordinated, informed care.

In this tutorial, you will:

• Register new patients
• Manage patient demographics and contact information
• Record medical history and allergies
• Create and manage diagnoses with ICD-10 coding
• Develop treatment plans
• Manage patient documents and attachments

Prerequisites¶

• 4Geeks Health account with Practitioner or Administrator role
• Patient information to register
• Understanding of ICD-10 coding basics

Step 1: Register a New Patient¶

1. Go to Patients → Add Patient
2. Fill in the registration form:

Demographics¶

Contact Information¶

Insurance Information¶

1. Click “Save” to create the patient record

Step 2: Record Medical History¶

Past Medical Conditions¶

1. Go to the patient’s profile → Medical History tab
2. Click “Add Condition”
3. Search for the condition using ICD-10 code or name:
4. Type “diabetes” → Select “E11 - Type 2 diabetes mellitus”
5. Type “hypertension” → Select “I10 - Essential hypertension”
6. Enter additional details:
7. Date of diagnosis: When the condition was first identified
8. Status: Active, Resolved, In remission
9. Notes: Additional clinical context
10. Click “Save”

Allergies and Adverse Reactions¶

1. Go to Allergies tab
2. Click “Add Allergy”
3. Enter allergy details:
4. Allergen: Medication, food, environmental, other
5. Reaction type: Rash, anaphylaxis, nausea, etc.
6. Severity: Mild, Moderate, Severe, Life-threatening
7. Onset date: When the allergy was first noted
8. Click “Save”

Critical: Allergies are displayed prominently on the patient’s profile and generate alerts during prescription ordering.

Medications¶

1. Go to Medications tab
2. Click “Add Medication”
3. Enter current medications:
4. Medication name: Search from drug database
5. Dosage: Amount and frequency
6. Route: Oral, IV, topical, etc.
7. Start date: When the medication was started
8. Prescribing provider: Who prescribed it
9. Status: Active, Discontinued, Completed
10. Click “Save”

Step 3: Create a Diagnosis¶

During a Consultation¶

1. Go to Clinical Care → Consultations
2. Select the patient or create a new consultation
3. In the Diagnosis section:
4. Click “Add Diagnosis”
5. Search ICD-10 codes by name or code number
6. Select the appropriate code
7. Specify:
   • Primary or Secondary: Main diagnosis vs. contributing factors
   • Status: Provisional, Confirmed, Ruled out
   • Notes: Clinical observations supporting the diagnosis
8. Click “Save”

ICD-10 Code Search¶

The system supports multiple search methods:

Step 4: Develop a Treatment Plan¶

1. Go to the patient’s profile → Treatment Plans tab
2. Click “Create Treatment Plan”
3. Fill in the plan details:

Treatment Plan Components¶

Example Treatment Plan¶

Plan Name: Type 2 Diabetes Management
Diagnosis: E11 - Type 2 diabetes mellitus
Start Date: March 1, 2026
Expected End Date: Ongoing

Objectives:
- Maintain HbA1c below 7.0%
- Achieve target blood glucose range (80-130 mg/dL fasting)
- Weight reduction of 5% over 6 months

Interventions:
- Metformin 500mg twice daily
- Dietary consultation (bi-weekly)
- Exercise program (150 min/week moderate activity)
- Monthly HbA1c monitoring

Follow-up: Monthly consultation
Responsible Provider: Dr. Maria Rodriguez

Step 5: Manage Patient Documents¶

Upload Documents¶

1. Go to the patient’s profile → Documents tab
2. Click “Upload Document”
3. Select the file and categorize:
4. Document Type: Lab results, imaging, referral letter, consent form, insurance card
5. Date: Document date
6. Description: Brief description of contents
7. Tags: Searchable tags for easy retrieval
8. Click “Upload”

Supported File Types¶

• PDF documents
• Images (JPEG, PNG) — X-rays, photos
• DICOM files — Medical imaging
• Text files — Notes, reports

Document Management¶

• Search: Find documents by type, date, or tags
• Preview: View documents inline without downloading
• Share: Securely share documents with other providers
• Version Control: Track document revisions
• Retention: Automatic archiving based on retention policies

Step 6: View the Patient Timeline¶

The Patient Timeline provides a chronological view of all patient interactions:

Using the Timeline¶

1. Go to the patient’s profile → Timeline tab
2. Filter by event type, date range, or provider
3. Click any event to view details
4. Add notes or follow-up tasks directly from the timeline

Best Practices¶

Data Quality¶

• Complete demographics: Accurate contact info ensures effective communication
• Update allergies immediately: Critical for patient safety
• Use specific ICD-10 codes: More specific codes improve billing accuracy
• Document thoroughly: Good documentation supports continuity of care

Privacy and Security¶

• Access only what’s needed: Follow minimum necessary principle
• Log out when away: Always lock your session
• Verify patient identity: Confirm identity before accessing records
• Report breaches immediately: Follow your facility’s incident response protocol

Efficiency¶

• Use templates: Create consultation and treatment plan templates
• Leverage auto-suggestions: ICD-10 code suggestions speed up coding
• Batch document uploads: Upload multiple documents at once
• Use the timeline: Quick overview of patient history without navigating multiple tabs

What’s Next?¶

• Learn about Clinical Procedures & Progress Notes
• Explore Automating Billing & Revenue Cycle Management
• Set up the Patient Portal

Need Help?¶

• Documentation: docs.4geeks.io/en/health
• Support: Available through the platform
• Book a Demo: 4geeks.io/en/contact

Still questions? Ask the community.