50 Opening John Test`s Health Care Record

50 Opening John Test`s Health Care Record

Health One

Version 7.1 User Manual. Copyright

2011Helix Health Ltd

Transactions & Items

In this session we apply some of the techniques learnt so far. Our patient, John Test, has visited the surgery complaining of a painful lump on his neck.

We assume that he is the first patient of the day and you have not yet started the HEALTH

one™

program.

Starting the Program and Logging In

Start the HEALTH

one™

program and login.

HEALTH

one™

opens and the Patient selector window appears.

If you are unsure about starting HEALTH

one™

and logging in refer back to the beginning of the previous session.

Opening John Test’s Health Care Record

We practiced this in the previous session:

1) If the Surname filter is not currently selected (cursor flashing) click

 once in the white box above the

Surname

column heading.

Surname filter is now selected

2) Type

Te

The list of patients reduces to display only those whose surname begins with ‘Te’’

3) Select

John Test

in the patient list.

4) Click on the

Select

button.

The Health Care Record (HCR) for John Test opens.

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Creating a New Transaction

To record the visit of John Test we need to add a page to the medical chapter of his HCR. To do this we simply create a new Medical Chapter

Transaction. The new transaction will be added to the end of his file.

1) Click once on the

Create Medical Transaction

button on the Transaction Panel Toolbar. (See reference sheet).

The Transaction Properties dialogue box appears

– see Fig.3.1

Transaction Attributes

In the previous session we mentioned that each transaction has a set of

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Transaction Properties dialogue box above.

Responsible:

Specifies the name of the person responsible for creating or maintaining this transaction. This list shows the name of the person logged on and the names of any other people that have delegated their right to create transactions to the logged on user.

Note: There is also an attribute called Author (not displayed on the

Transaction Properties dialogue box) which is automatically set to be the name of the person who validates the transaction

– see

Transaction Status later in this session.

Date of event:

Automatically set to the current date and time. Note: You can change this if, for example, you are updating a patient’s HCR at a later point in time.

Speciality:

This is another drop down list that specifies the medical speciality being recorded. In general practice this is useful when a consultants report pertaining to a speciality is being recorded, or, for example, a patient is being admitted to hospital. In most cases the speciality would be ‘General Practice’.

Legal Structure:

HEALTH

one™

can define a person as performing one

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Physician, and this box can be ignored.

Comment: This new box gives the user additional flexibility in tagging transactions. You can insert any free text you like here.

Alternatively you can use an associated list of preferred terms that can be defines using the configuration tool.

Problem:

The concept of problems was mentioned in the previous session. This is where a transaction is declared as being related to an existing problem.

Note:

This can be completed later when the reason for the visit is known.

2) Complete the Transaction Properties dialogue box by observing the lists for the attributes and then setting their values as follows:

Type

Contact

Name

Responsible

Date of event

Speciality

Consultation

Your name

Current date and time general practice

Legal Structure

Physician/general practice

Problem

None

3) Click on the

OK

button.

New transaction is completed and appears at the end of John

Test’s medical chapter. See Fig.3.2. It is printed in Bold and

Italic (see the Transaction Status information box below)

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Shortcut to Creating a New Transaction

It is possible to create new transactions directly from the patient selector.

Below is a screen shot of the patient selector:

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Shortcut to Creating a New Transaction

The three consultation types available are the first three transaction names that have been defined in the configuration tool. You can change the consultation types, and the icons associated with each, by opening the configuration tool.

The first three consultation types in the list are those available in the patient selector of HEALTH

one™

. You can move a name on this list up or down by clicking on the name and dragging it to your preferred position in the list.

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The Item Selector

HEALTH

one™

items are accessed via the Item Selector window

–this displays a dictionary of all the items in HEALTH

one™

.

Clicking on the Item Selector Button on the Item Panel Toolbar, illustrated below, will display the selector window (see fig 3.3).

Inserting Items

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1) Ensure that the newly created transaction is selected in the

Transaction Panel and then click once on the Item Selector Button.

Item Selector dialogue box appears.

2) Click on the

Sorted

option.

Tick (called a Check Mark) appears in the Sorted option check box and the list is sorted into alphanumeric order.

3) Uncheck the

Sorted

option by clicking on it once again.

4) If the

Synchronous

option is unchecked

– check it now by clicking on it.

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5) If the

Leading

option is unchecked

–check it now. Type:

as

Only Items that begin with ‘as’ are displayed

6) Uncheck the

Leading

option.

All Items that contain the letters ‘as’ together anywhere in their name are displayed.

7) Delete the as in the Find box.

Full list of items appears once more

8) Uncheck the Synchronous option.

Refresh button activates

9) Type in capitals: IC

Nothing happens

10) Click once on the Refresh button.

All Items that contain the letters ‘IC’ together anywhere in their name are displayed.

11) Check the Synchronous option.

Refresh Button de-activates

– screen stays the same because

Synchronous is active and filtering on ‘IC’.

12) Check the Match Case option.

Only Items that have upper case (capital) IC anywhere in their name are displayed.

13) Uncheck the

Match Case

option.

Now we will locate the first item needed to record this visit of John Test.

Firstly, set the Item Selector options as follows:

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Match Case

Leading

Sorted

Synchronous

= Unchecked.

= Checked

= Unchecked

= Checked.

We need to locate the Item:

subjective symptoms

1) Delete the

IC

in the Find box and type su



All items beginning with ‘su’ are now displayed.

2) The Item subjective symptoms should already be selected, if not, select it now by clicking on it once.

3) Click on the

OK

button

The Item Selector box closes and the Item ‘subjective symptoms’ is added to the transaction detail panel and its associated list appears.

We will look at the Associated List in more detail later. To continue:

4) Click once on the Associated List

Close

button.

Associated List box closes and Subjective Symptoms dialogue box is active.

Showing/Hiding the Item Attributes Panel

1) To show or hide the Item Attributes panel click on the illustrated

 button once. Click again to close.

The Item box should now appear as in Fig.3.4

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Typing and Editing Text

Typing and editing follows the usual text editing techniques:

1) Type the following:

This is a line of text typed by

your

name

2) Press the Backspace key repeatedly to delete your name and the text

‘typed by’

Text now reads ‘This is a line of text’

3) Use the Left Cursor key to move the flashing insert cursor to before the l of line. Type: new

Text now reads ‘This is a new line of text’

4) Drag across the words a new to select them and type: an old

Text now reads ‘This is an old line of text.

5) Drag and select the entire line of text. Press the Backspace key.

Text deleted.

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The Item Dialogue Box

Term Lists

HEALTHone™ is designed to keep the amount of typing necessary to maintain a patient’s record to a minimum. This is achieved by selecting

terms

from various sources and supplementing these with typing if necessary. The three most common sources of terms are:

The Term Dictionary

A complete list of terms known to

HEALTHone™

The Associated List

A list of terms related to the current Item.

The Permanent List

A list not related to a specific item that expresses degree, intensity, size etc as opposed to a particular complaint.

To display a list you click on its illustrated button on the Item dialogue box toolbar.

There are a number of good reasons to use lists as opposed to typing:

Firstly It saves you time because it is quicker to choose a response from a list than type it yourself.

Secondly I t’s easier, there is no need to remember the spelling of complicated medical terminology.

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Thirdly It is more consistent, you are more likely to express a condition in a similar manner using terms from a list as opposed to typing a response. This can become very important when analysing your patients later and locating occurrences of a particular illness or condition.

Using the lists takes a little effort at the beginning but very quickly becomes far more efficient than typing. In short, we encourage you to use the lists wherever possible.

The Term Dictionary

OK, now to continue with John Test:

1) Click once on the Term Dictionary Button

Term Selector Window appears

2) Ensure that only the Leading and Synchronous options are checked.

3) Type: nec

List reduces to only terms beginning with ‘nec’

4) Select the term: neck pain

5) Click on the OK button.

‘Neck pain’ inserted as a response and the selector window closes.

The Permanent List

John Test describes the pain as acute. To record this we use the

Permanent List:

1) Click once on the Permanent List Button.

Permanent List appears.

2) Select the term: acute, press the RETURN key

Acute sub-list appears

3) Ensure that acute is still selected and click on the Insert button.

Item response now reads ‘neck pain acute’

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Selecting / Deleting a Term

A term selected from one of the lists is treated by

HEALTHone™ as a complete unit, i.e. the term

acute

can only be deleted entirely not as individual letters

a c u t e

.

1) Press the Backspace key until the term acute is deleted

The ENTIRE te rm ‘acute’ is deleted.

2) Click once anywhere in the neck pain

The entire phrase ‘neck pain’ becomes highlighted to indicate that it is selected

To cancel a selection:

3) Press the Right Cursor key to move the Insert Cursor away from the selected term.

‘neck pain’ is no longer selected.

Associated Lists

Many Items have a list of common terms associated with them which is displayed in the Associated List Selector dialogue box.

1) Click once on the Associated List Button.

Associated List dialogue box appears.

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List Options

These are identical in meaning to the Item Selector dialogue box and the only new objects are the List Type selector and History Box. The list type selector provides an alternative way to display the Permanent

List we used a moment ago.

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The History Option Box

To use the History box you need to understand how the list is structured.

List Structure

This particular item,

subjective symptoms

, has terms associated with it which themselves have a list associated with them. You will know when a term has a list of its own because the icon illustrated will appear to the left of it.

As an example, take the term ‘common’ and the further selection of one its terms ‘sore throat’.

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The History Box notation displays the name and level of the current list being viewed. The more sub-lists you select the higher the level number will become. In addition the History Box can be used to move easily to a different level by clicking on the down arrow to its right and selecting the level required.

Navigating the List:

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1) Click once on the term: common to select it and then press the Right

Cursor Key once.

Sub-

List for ‘common’ term appears and History Box displays

‘0:common’

2) Use the Down Cursor key to select the term sore throat, now press the

Right Cursor key once again.

Sub-

List for ‘sore throat’ term appears and History Box displays

‘1:sore throat’

3) Press the Left Cursor key once to return to the list 0:common.

4) Press the Left Cursor key again to return to the full list of associated terms.

5) Spend a little time experimenting with the Up, Down, Left and Right cursor keys to see their effect.

6) Click once on the Close button

Associated List dialogue box closes

7) Click once again on the Associated List Button to re-open the dialogue box.

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Using a Term as a Response

The cursor keys are used to navigate the various terms and lists, however, to use a term as a response simply select it press the RETURN key. If the term has a sub-list this will be displayed as well as the selected term being placed into the Item dialogue box. If the selected term does not have a sub-list pressing the RETURN key will use the term as a response and the Associated List dialogue box will automatically close.

1) Ensure that the term common is still selected, press the Right Cursor

Key once to display the sub list.

2) Use the Down Cursor key to select the term lump, and press the

Return key.

The Item dialogue box now reads ‘neck pain lump’ and the associated list box has closed.

3) Click the OK Button.

Item dialogue box closes and the Transaction Detail Panel appears as shown:

Note : If you do not wish to use Associated lists it is possible to disable them. To do this click on the menu item « tools

– options ».

They can be restored at any time.

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Automatic Item Selector Display

The Subjective Symptom Item is now complete. Next, we will record the

Objective Findings.

To place another Item into this transaction for John Test we would normally click on the Item Selector Button on the Item Panel Toolbar, however,

HEALTHone™ will automatically assume you are searching for an item as soon as you type! It will also display the dialogue box with the list filtered on what was typed.

1) Type an: o

The Item Selector dialogue box appears with the items beginning with ‘o’ already displayed.

When you are familiar with

HEALTHone™ you will realise that this is an advantage because it saves you time, however, at first it can be confusing.

2) Click once on the Cancel button. The Item Selector dialogue box closes.

More Items

Inserting the Objective Findings Item

1) Click once on the

Item Selector Button

on the Item Panel Toolbar.

2) Type: ob in the Find Box

Item list reduces to those beginning with ‘ob’

3) Ensure that the Item objective findings is selected and click once on the OK button.

The Item ‘objective findings’ is placed into the transaction detail panel and its associated list box opens automatically.

The term we require is not in the Associated List but in the Term

Dictionary:

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4) Click on the Close button to close the Associated List dialogue box. (or press ‘Esc’).

5) Click once on the Term Dictionary Button.

Term dictionary now appears

6) Type:

seb

in the Find box and select the term

sebaceous cyst

, click on

OK

Term ‘sebaceous cyst’ entered as a response and the dictionary closes.

We will now supplement this term with additional text:

7) Type:

2 x 2 cm

Response now reads ‘sebaceous cyst 2 x 2 cm’

8) Click on the

OK

Button to complete this Item.

Transaction detail Panel now has two items entered.

Inserting the Assessment Item

1) Click once on the Item Selector Button on the Item Panel Toolbar.

2) Type: as in the Find Box

Item list reduces to those beginning with ‘as’

3) Ensure that the Item assessment is selected and click once on the

OK button.

The Item ‘assessment’ is placed into the transaction detail.

The Assessment Item does not have an associated list.

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4) Use the Item Dictionary to enter the term sebaceous cyst as a response.

5) Type: back of

6) Use the Item Dictionary to enter the term neck as a response.

Response now reads ‘ sebaceous cyst back of neck’

7) Click once on the OK button.

More Items

The Assessment Item is now completed and your screen should appear as in Fig.3.5 below:

Lastly, we will complete this session by inserting the Plan of Action Item:

Inserting the Plan of Action Item

1) Click once on the

Item Selector Button

on the Item Panel Toolbar.

2) Type:

pl

in the Find Box

Item list reduces to those beginning with ‘pl’

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3) Select the Item

plan of action

and click once on the

OK

button.

The Item ‘plan of action’ is placed into the transaction detail panel and its associated list box opens automatically.

Skipping a Term as a Response

This time we wish to use a term from a sub-list but omit the term the list belongs to:

4) In the Find Box type:

pr

. Ensure the term

procedure

is selected and press the

Right Cursor

key once.

The sublist for ‘procedure’ is displayed but the term is not placed in the Item dialogue as a response.

5) In the Find Box type:

ex

, and ensure that the term

excision

is selected. Press the

Return

key.

The sublist term ‘excision’ appears as a response and the associated list box closes.

6) Type:

shelled out successfully

Click on the

OK

button.

Inserting a Repeat Item

Sometimes, for presentation purposes or because there is a great deal of typing required as a response or because there is more than one condition to be recorded, it may be necessary to use more that one item of the same name. You can use as many items of the same name as you require in a transaction.

HEALTHone™ has a quick procedure to do this; simply select the item to be repeated and type an

=

.

1) Ensure that the newly created

plan of action:

item is selected in the transaction detail panel. Press:

=

(

equals key

)

A new ‘plan of action’ item is created and its associated list appears.

2) The first term

follow up

is the one we require. Press the

Return

key.

The term ‘follow up’ is used as a response and its sub list

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3) Select the term

1 week

in the sub-list and press

Return

.

4) Click

OK

to close the plan of action dialogue box.

Your completed transaction should now appear as in Fig. 3.6.

Saving a Patients File

Whenever you have created a new transaction or made changes to a patients file you should save the file.

HEALTHone™ transactions can be

Saved or Validated or Saved and Validated at the same time.

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A Saved transaction is one that has been written to the patients file and will be available the next time the file is opened, however; it will not become part of the

HEALTHone™ audit trail until it has been validated.

To save a patients file you select Save from the File Menu.

1) Select

Save

from the File Menu

-

Validation prompt appears.

2) Click the

Validate

Button.

3) Select

Close HCR

from the File menu.

File closes and the Patient Selector window is once more in view.

Note: By option you can skip the confirmation dialogue when saving a transaction

– the transaction will be validated automatically. To do this click on the menu item « tools

– options » and tick the option «CTRL+S validates transactions without confirmation». Then press CTRL+S to save and validate when in a patients file.

Closing the HEALTHone™ Program

To close the

HEALTHone™ program you simply select Exit from the File

Menu.

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1) Select

Exit

on the File menu

Close dialogue box appears.

2) Click on the

Yes

button or simply press the

RETURN

key.

HEALTH

one

program closes and you are returned to the desktop.

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Summary Guide

Create a new Medical Transaction

Click on the New Medical Transaction button on the TRANSACTION

PANEL Toolbar. Complete the transaction properties box.

Insert a new Item

If you know the name of the item you require simply type its name when the transaction detail panel is active. Otherwise, click on the Item

Selector button on the ITEM PANEL Toolbar and select the required item from the list.

Display / Change the attributes of an item.

First ensure that the item is open for editing by selecting it and pressing the RETURN key. Now click on the attributes panel button to display these. Click once again on the same button to hide these.

To display the term dictionary when editing an item.

Click once on the blue book on the item dialogue box toolbar or type

Ctrl + T

To re-display the associated list when editing an item

If an item has an associated list it will automatically open when the item is opened for editing. To re-display it once closed click once on the associated list button on the item dialogue box toolbar or type

Ctrl + A

To display the permanent dictionary when editing an item.

Click once on the permanent list button on the item dialogue box toolbar or type

Ctrl + P

To navigate an associated list

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If the term required has no sub list of its own simply press RETURN to include it as a response. If the term has a sub list of its own, you can:

Press

RETURN

– include term and display sub list.

Press right arrow to exclude term and display sub list.

Click on the term with the

Right

mouse key to display a menu. Now click on SELECT to include the term without displaying the sub list.

Press left arrow to return to the term from a sub list.

Repeat an Item

Select it and press the equals key.

Save a patients file

Select the menu sequence

File

/

Save

Own Notes

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