Chapter 8 - PatientsTable of ContentsChapter 10 - Rabies


CLINICAL & MEDICAL RECORDS

It is important to understand the difference between Clinical Records and Medical Records. When a Point of Sale Billing Transaction is completed, the system automatically records the line items (Procedures) for that transaction in the Clinical Records. Medical Records is a free-form area where you may manually enter any comments, etc. that you wish. If you are interested in being a "paperless" clinic, you would write all the things that normally go in a file in the Medical Records. This chapter is divided into two sections, section I is Clinical Records and section II is Medical Records. To utilize some of the special features of Medical Records it is necessary to have Vpf (Chapter 27). These features are discussed in this chapter and are denoted by (*Vpf*).

PLEASE NOTE: If you make an entry in the Medical Records, the system will make a notation in the Clinical Records that Medical Records have been entered. If you wish to turn this feature off, add the abbreviation .<FlO with text = [NULL) (see ABBREVIATIONS). To change the wording of the notation add .<FlO, and whatever you type as the text will override the default notation of "/* FlO Med Rec added this date."

 


 


I. CLINICAL RECORDS
A. Entering a Notation
B. Entering a Problem Code
C. Listing Patients' Clinical Records
D. Parasite Test Results
E. Front Desk Transaction
F. Printing Clinical Records
G. Deleting Entries in Clinical Records
H. Deleting All Clinical Records for Specific Years
I. Find Data in Clinical Records



II. MEDICAL RECORDS
A. Entering Records
B. Printing Medical Records
C. Major Problem List (Vpf)
D. Templates (Vpf)
E. Menu/Help
F. The + Feature (Vpf)

CLINICAL RECORDS

With V/BOSS you may choose whether to keep track of all clinical records, or just certain categories, or certain procedures within a category, for a Patient on your computer system. This eliminates having to write up the procedures you perform in a folder. Using the Clinical Records Option, all procedures (or those of the categories you have chosen) booked in the Billing Section will automatically be entered into the clinical records and can later be viewed from the Patient screen by pressing <F6>. Clinical Records are also created when you register a new Patient and enter the last vaccination dates. Your system comes set up to keep track of everything in the clinical records unless your contract specified Medications Only or NO Clinical Records. When viewing the Patient screen, option <F6> will read "Clin Recs" if you are configured for Clinical records, "Medi" if you are configured for Medications only, and will not appear if you are configured for NO records. See the chapter on PROCEDURES in this Guide if you wish to turn the feature off for particular categories or procedures.

IF YOU ARE CONFIGURED FOR MEDICATIONS ONLY, YOU MUST BE SURE TO ENTER ALL MEDICATIONS DISPENSED UNDER THE "DISPENSING" HEADING ON BILLING SCREEN # 2 WHEN BILLING SOMEONE FOR MEDICINE.

A Notation or Problem can be entered into the Patient's Clinical Records from the following screens:

Patient Screen-->

<F6> ClinRecs-->

<F6> Add (this is easiest)

Work In Progress-->

<F4> Cl-Recs-->

<F6> Add

Recall Screen-->

<F4> Cl-Recs-->

<F6> Add

P05 Billing-->

<F6> Cl-Recs-->

Automatic addition

A. To Enter a Notation in Clinical Records,

after using any of the above methods: You will be prompted to enter "P/N", (P for Problem Code, N for Notations), press [N]. Next you will be prompted to enter the Provider code. Enter the Provider code (if only one character press <Enter> after the character). A line will be displayed for you to enter the Notation. Enter the Notation and press <enter>. Follow the same steps for each line of Notation you wish to enter. This is useful for entering any type of comments necessary, or for test results that were not available at the time of billing.

 

 

B. To enter a Problem Code in Clinical Records,

you follow the above steps, but enter [P] for problem Code. After you enter the Provider code, a short line will display for the problem. Once entered another line will display for you to enter any action taken. The action taken entry is optional.

 

 

Notice at the bottom of the screen "<F4> Clinical Lookup". Pressing <F4> will display a lookup window for the diagnostic abbreviations. Using the up or down arrows, you may select an abbreviation to insert into your notation or problem code. When using the problem code you may use the abbreviations for both the problem and the action taken. See ABBREVIATIONS for information on adding, deleting and modifying the abbreviations.

C. To list Patients' Clinical Records,

find a patient and at the "Patient Screen", press <F6> Clin Recs. All Medication, Procedures, and Notations administered to the patient, that you have requested the system to record, will be displayed on the screen within their appropriate categories. Should the screen be filled before all information has been displayed, you will be prompted to "ENTER ANY KEY TO CONTINUE". This will reoccur until all information for this patient has been displayed. On the next page is an example of this screen.

Using the <F2> key, you may change the order of the Clinical records display. If the records are displayed by date pressing <F2> will change the display to category sort. Pressing <F2> again will redisplay the date sort. This feature allows you to view all procedures performed on a certain date or to view, for example, all Laboratory tests ever performed. The first two pages of this chapter show the two different sort orders.

Through use of the abbreviation .Csrt you may choose the default order, that is, the order that the records will display in when you first access them. Regardless of the default order, you may still toggle between them by using <F2>. See ABBREVIATIONS for information on adding or modifying this type of abbreviation.

If you know the case number of a particular transaction that you wish to view, from the Clinical records display you may press <F7> for Show Case#. Then enter the case number. That transaction will then be displayed for you.

 

 

D. When a patient has been tested for parasites

the results will automatically register in the Clinical Records.

 

 

 

 

 

E. Front Desk Transaction

When a Front Desk Transaction has been billed, the Clinical Records will not be updated.

F. Print Clinical Records

To Print Clinical Records for a patient, select <F6> from the patient screen and the Clinical Records for this patient will be listed. Press [P]. You will be prompted to enter the format of the print out. Enter [C] for category sort or [D] for date sort. The Clinical Records for this patient will then be printed. The corresponding prices will also print unless you add the abbreviation .Cpr$ to the abbreviation file. The text for this abbreviation should be [N]. See ABBREVIATIONS.

G. Delete Clinical Records Entry

To delete an entry in Clinical Records, select <F6> from the patient screen and the Clinical Records for this patient will be listed. Press [D]. You will then be prompted to enter the Case No., this is a three digit number listed in each entry under the CASE field in the clinical records. After entering the case number all entries for that case will be listed. A flashing column to the left will list the ID for each entry. You will be prompted to enter the Blinking ID Number. Enter the number relating to the entry you want to delete. The entry will then be deleted. NOTE: You may designate a minimum Provider Security level allowed to delete Clinical Records, using abbreviation .Cdel, see ABBREVIATIONS.

H. Delete Clinical Records

You may delete Clinical Records for ALL patients up to and including a year of your choice. You should probably make a backup and archive it before beginning this procedure. From the Main menu select [4] File Maintenance, [C] Clinical Records, [D] Delete. Read the explanation displayed. Enter [Y] if you are sure you wish to delete records. Enter the last two digits of the year records should be deleted THROUGH. You will be given the option of having the deleted records printed or not. NOTE: You may designate a minimum Provider Security level allowed to delete Clinical Records, using abbreviation .Cdel, see ABBREVIATIONS.

If you prefer, you may delete Clinical Records for INDIVIDUAL Patients up to (but not including) a particular date. If you want a printed copy of these records, you should print them BEFORE making this selection. When ready to delete the records, from the desired Patient's screen press <F6> Clinical Records then [M] Mass Deletion. You will be prompted to enter the target date in the format YYMMDD (All records for this Patient PRIOR to this date will be deleted). You will be prompted "Are you absolutely sure?". Please double check the date entered, once you enter [Y] the records are gone.

You may view statistical information about the number and percentage of Clinical Records that exist on your system. From the Main Menu type [H] for Help. The Help Menu Bar will display. (See the Menu Bars Appendix for help with using this menu style.) Arrow right 5 times to Misc. Type [C] for Clinical Records Stats. The number and percentage of records for each year will be calculated. You may wish to view this information to help you decide if and which records to delete.

I. Find

Find allows you to search the Clinical Records for any desired data string (text or numbers). From Clinical Records, press <F8>. In the indicated field enter your search string. Any records containing that data will be displayed.

MEDICAL RECORDS

Remember, some of the features described in this section require Vpf. Watch for the symbol (*Vpf*) denoting these features.

If you use the Medical Records extensively, much higher performance may be achieved in processing the Medical Records (especially for slower terminals and remote stations) by setting the terminals' Memory Occupation to 3 in the ID Records (see ID RECORD).
|*PATIENT*| is supported in the Medical Records (*Vpf*). If you have Desktop, you may access it from Medical Records by holding down <Shift> and pressing <F2>.

A. To enter data on a Patient's Medical Record,

press <FlO> Other and press <FlO> Med-Rec while at the Patient Screen. A "notepad" appears, which you can use to keep medical comments, etc. A "page" is 8 lines long. Two "pages" are displayed at one time on the screen. Hundreds of pages are available for each Patient, so don't worry about running out. If Medical Records are present for a Patient "Fl0 Recs" will flash near the top of the screen to the left of the Patient number.

Only one user may access the same Patient's Medical Records at a time. If you try to access a Patient's Medical Records and someone else is currently in it, a warning message will display and you will be denied access until the other user has exited from that record.

These keys have a function in the Medical Record:

<Down arrow>

down a line

<Up arrow>

up a line

<Left arrow>

move left

<Right arrow>

move right

<FlO>

next page

<F2>

previous page

<INS>

inserts text or spaces at cursor & moves following text to the right

<DEL>

deletes character at cursor & moves following text to the left

<space bar>

deletes character at cursor & moves cursor to the right

<F9>

saves and ends entry of data


When you wish to exit from the Medical Record, press <F9> to save and return to the Patient Screen. <Fl> will exit WITHOUT saving.

Listed below are definitions of the function keys.

<Fl> Exit

Exit Medical Records making no changes.

<F2> PgUp

Page through previous pages of the Medical Records (if there are any).

<F3> Print

Print the selected patients Medical Records.

<F4> Ins Pg

Inserts a page before the one you are currently on.

<F5> New Client

Returns you to the Client Search Menu without updating the Medical Records.

<F6> Ins Line

Inserts a line on the current page.(Use also the <Ins> key)

<F7> Del Line

Deletes a line on the current page.(Use also the <Del> key)

<F8> Menu/Help

Displays the Medical Records features menu.

<F9> Save Quit

Saves the newly entered records and returns you to the patient screen.

<FlO> Page Down

Pages down through the Medical Records.

<Ctrl-L> MPL

Displays the Major Problem List. Press <F4> to modify it.

<Ctrl-I> In.Vet.Cl

If Instructions for veterinary Clients is active on your system, you may access them from here.

<sF2> Desktop

This is <Shift-F2>. If Desktop is active on your system, you may access it from here.

<Ctrl-V> VpfNotes

Displays the starting window for VpfNotes. See the appendix on VpfNotes.

<Ctrl-T> Temp

Displays a Template look up window.

B. Print Medical Records

To print a Patient's Medical Record, press <FlO> Other and press <FlO> Med-Rec while at the Patient Screen. At this time the last page entered will be displayed. Press <F3>, Print, and V/BOSS will prompt you to enter the starting and ending pages. Make sure the printer is on-line and after entering the ending page the medical records will begin printing.

C. Major Problem List (*Vpf*)

Medical Records include a separate Major Problem Listing. Viewing of the Major Problem List is available from the Patient's Recall screen, Clinical Records screen, Work in Progress and Medical Records. From Medical Records ONLY, you may press <F4> to modify (or enter) Major Problems. From any of the above mentioned screens, hold down <Ctrl> and press [L] to access the major problem list.

 

 

Problem List is a single page ONLY!!!

D. Templates (*Vpf*)

You may create templates in the Client Information System of the V/BOSS master record (00000). These templates may be inserted into patients' records without having to re-key everything for each patient.

Examples:


 

 

1. To create the templates, go to the client search screen (<F5>) and enter (00000)<Enter>. You will now be in the V/BOSS master record. Press <FlO> for Info.

Each individual template must be given a name. The name MUST be on the first line of the page and MUST include [~###] and a word or words to identify the template, for example [URINALYSIS]. You MUST replace the #'s with a 3-digit number that matches the page number that you are on. For instance, if you are entering the template on page 001 of the information system the template must be named 001. The name must be on the first line of the template and start in the first position of that line. The exception to this is when you have a template that needs more than eight lines, so you must continue on another page or pages. In that case you must still enter [~###] on the first line and positions of the additional page(s) but you will use the number that corresponds to the first page of the template in question. The next template after a "spanned" template should contain the number that matches the page number that it starts on.

 

 

 

Use the following bracket types to insert the information you wish to track:

{ } will insert numerical information.

[ ]will insert alpha or numeric information.

[DD/DD/DD] will insert current date when this field is bypassed.

[] used with no spaces in between them will insert a blank line.

These brackets must be used when you create your templates. However, if you would like different deliminators to appear in the Patient records you may create the abbreviation .Cl[] . If you have a color monitor, you may also wish to use the abbreviation .Cmpx to cause highlighting of bracketed information. (see ABBREVIATIONS)

2. To use in a patient record, find the patient and press <FlO> for other, then <FlO> again for Med.Rec. Type the number (name) for the template that you wish to have inserted into this record (e.g. 001, etc.). Fill in as necessary. You may only fill in the areas enclosed by brackets.

If you are on a blank page of a Patient's Medical Records, you may hold down <Ctrl> and press [T] to lookup the available templates. Use the <Up> or <Down> arrows to scroll through the templates. If you wish to insert one, press <Enter> while viewing it. <Fl> exits from template lookup without selecting one.

E. Menu/Help

Pressing <F8> from Medical Records displays a menu bar of additional features. Most of these features involve moving around within the Medical Records. If you are unfamiliar with the use of menu bars, see the MENU BARS chapter of this guide before attempting to use the Menu/Help selection.

 

1. Go to Page [xxx]

This function may be used to go directly to a particular page of the Medical Records. Either press [G] or if that selection is highlighted, press <Enter>. You will see:

 

 

You may enter the desired page number, press <F2> to go to page 001 of Medical Records, or press <FlO> to go to the last page that has an entry on it.

2. END Page Position

Press [E] or highlight this selection and press <Enter> to go to the last page that has an entry.

3. TOP Page Position

Press [T] or highlight this selection and press <Enter> to go to page 001 of the Medical Records.

4. Find Data String (*Vpf*)

This function may be used to find any data desired within a Patient's Medical Records. You may search for dates, abbreviations, words, phrases, etc. Keep in mind that the system will be looking for an exact match for the string you enter. For example, if you enter [HEARTWORMS] as the string to find, the system will ignore variations such as [HWORMS], [HW], etc. The key is to be CONSISTENT and use abbreviations as much as is feasible.

Press [F] or highlight this selection and press <Enter>. You will see:

 

 

Using any of the listed methods, ensure that you are on the page where you wish the search to begin. Enter the string to be searched in the space provided. If a match is found, you will be taken to the first page that contains the match. If you think that there is a match on more than one page, repeat the search process starting with the page you are on. If no match is found you will see the message "Sorry, no matches found".

5. Peruse Portfolio (*Vpf*)

This function scrolls through the Medical Records page-by-page until it reaches the last page with an entry or you press any key to stop the scrolling. You should go to the page that you want to start with before activating the peruse mode. When at the desired page, press [P] or highlight the selection and press <Enter>. See below for information on altering the peruse speed.

6. Set Peruse Time (*Vpf*)

This function allows you to set the length of time (in seconds) that the system will pause at each page when in peruse mode. Enter [S] or highlight the selection and press <Enter>. Then enter the number of seconds. The minimum allowed is [1] and the maximum is [9].

 

 

7. Update Patient Fields

This function allows you to modify the Patient's special fields. Use the right arrow to move to Misc. then press [U] or highlight the selection and press <Enter>. Be sure to press <FlO> to save any changes you make.

8. Patient Weight/Temperature Display

This function displays the Patient's weight and temperature history. Two abbreviations must exist with [Y] as their texts, .Pwei and .Ptem. Also there must be a Patient Special Field called [Temper.] that you update. Use the right arrow to move to Misc. then press [P] or highlight the selection and press <Enter>.

9. Clinical Records

This function allows you to access the Patient's Clinical Records. Press [C] or highlight the selection and press <Enter>.

10. Reformat/Compact

This function removes any blank pages that exist between pages with entries. Use the right arrow to move to Misc. then press <Enter>.

F. The + feature (*Vpf*)

This function allows you to import instruction files into the Medical Records. To do so you need to know the name of the instruction file to be imported (File Maintenance, Instruction Files Maint, List Instructions). Instruction Files that are to be used in this way should have the word [END] at the beginning of the first blank line after the last written line of the instruction.

When you want to import an instruction into the Medical Records type [+FILENAME) on any blank line. You must type this starting in the first position of the line. Do not put a space between the + and the name of the file. See below.

 

 

After typing the filename, press <Enter>. The instruction will then be imported. This feature may also be used in Take Home Instructions (*Vpf*). If the abbreviation .Wicp exists with text of [Y], the Take Home Instructions are automatically stored in the Medical Records after the receipt is printed.


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