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Medical records

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This section describes how to access, manage, and utilize patient medical records within 4Geeks Health. The medical record is a comprehensive and confidential collection of a patient’s health information, serving as the foundation for clinical decision-making and continuity of care.

What is a Medical Record?

In 4Geeks Health, the medical record is a digital repository for all information related to a patient’s health, including:

  • Demographics: Basic patient information (name, date of birth, contact information, etc.).
  • Medical History: Past medical conditions, surgeries, allergies, medications, immunizations, family history, and social history.
  • Encounters: Records of all interactions with healthcare providers (outpatient visits, inpatient stays, consultations, procedures).
  • Vital Signs: Historical records of vital signs measurements.
  • Progress Notes: Notes documenting the patient’s progress and the provider’s assessments and plans.
  • Orders: Medication orders, lab orders, procedure orders, and other orders.
  • Results: Lab results, imaging reports, and other diagnostic results.
  • Documents: Scanned documents, images, and other attachments.

Accessing Medical Records

The primary way to access a patient’s medical record is:

  1. Patient Search:

    • Use the main search bar (usually at the top of the screen) to search for the patient by name, ID number (MRN), or other identifying information.
    • The system should provide suggestions as you type.
    • Select the correct patient from the search results.

  2. Patient List:

    • Navigate to the “Patients” section (likely from the main navigation menu).
    • Browse or filter the list of patients to find the desired patient.
    • Click on the patient’s name or ID to open their record.

The Medical Record Structure

The medical record is typically organized into sections or tabs to make it easy to find specific information. The exact structure may vary depending on your organization’s configuration, but common sections include:

  • Summary/Dashboard: Provides an overview of key information, such as demographics, allergies, current medications, recent encounters, and outstanding orders.

  • Medical History: Detailed information about the patient’s past medical history, including:

    • Problems/Diagnoses: A list of current and past medical conditions.
    • Allergies: A list of known allergies (medications, foods, environmental).
    • Medications: A list of current and past medications.
    • Immunizations: A record of vaccinations.
    • Surgeries: A list of past surgical procedures.
    • Family History: Information about medical conditions in the patient’s family.
    • Social History: Information about the patient’s lifestyle and habits (e.g., smoking, alcohol use, occupation).

  • Encounters/Visits: A chronological list of all interactions with healthcare providers, including:

    • Outpatient Visits: Records of office visits.
    • Inpatient Admissions: Records of hospital stays.
    • Consultations: Records of consultations with specialists.
    • Procedures: Records of clinical procedures.
    • Clicking on an encounter will usually open the detailed record for that specific interaction.

  • Vital Signs: A history of vital signs measurements, often displayed in a table or graph format.

  • Orders: A list of all current and past orders, including:

    • Medication Orders
    • Lab Orders
    • Procedure Orders
    • Therapy Orders

  • Results: A section for viewing results of lab tests, imaging studies, and other diagnostic tests.

  • Documents: A place to store and view scanned documents, images, and other attachments.

  • Progress Notes: Notes related to patient progress.

Managing Medical Records

  • Adding Information: You can add new information to the medical record in various ways, depending on the type of information:
    • Creating New Encounters: Documenting new visits, consultations, or procedures.
    • Recording Vital Signs: Adding new vital signs measurements.
    • Entering Orders: Creating new medication, lab, or procedure orders.
    • Updating History: Modifying the patient’s medical history (e.g., adding a new allergy or diagnosis).
    • Uploading Documents: Attaching scanned documents or images.
  • Editing Information (Limited): You may be able to edit some information in the medical record (e.g., correcting errors in demographic data or adding notes). However, many parts of the record (especially those related to completed encounters) are locked or have restricted editing capabilities to maintain data integrity and legal compliance. Corrections often require adding addenda or new entries.
  • Printing: You can usually print sections of the medical record or generate summaries.
  • Sharing (Controlled): 4Geeks Health may have features for securely sharing information from the medical record with other healthcare providers or with the patient (through the Patient Portal). This sharing must comply with privacy regulations.

Important Considerations

  • Confidentiality: Patient medical records are highly confidential. Access and disclosure of information must strictly adhere to privacy regulations (e.g., HIPAA in the United States, GDPR in Europe).
  • Accuracy: Ensure that all information in the medical record is accurate and up-to-date.
  • Completeness: Strive to maintain a complete and comprehensive medical record for each patient.
  • Legibility (for Handwritten Notes): If any part of the record is handwritten, ensure it is legible.
  • Audit Trail: 4Geeks Health should maintain an audit trail that tracks all changes made to the medical record, including who made the change, when it was made, and what was changed.
  • User Permissions: Different user roles have access to edit medical records.
  • Training: Provide proper training for staff.

This documentation provides a comprehensive overview of managing medical records in 4Geeks Health. Remember to adapt any specific section names, features, or steps to match your organization’s customized configuration. It’s crucial that all users understand the importance of maintaining accurate, complete, and confidential medical records.