Adding Basic Medical Information 7 0

Adding Basic Medical Information 7 0

Health One

Version 7.1 User Manual. Copyright

2011Helix Health Ltd

Adding Basic Medical Information

The Basic Medical Information is a transaction that records data such as allergies, past medical and surgical history, etc. It effectively acts like a summary chart in your manual notes. This is usually the first page in the

Medical Chapter and has a unique icon to represent it. Illustrated on the left,

Starting the Program

1) Start

HEALTHone™ and Login.

Patient selector window is now open.

Opening a Health Care Record

To open an existing patients HCR:

2) Type:

Te

in the surname filter

3) Select

Sarah Tennant

in the patient list.

4) Click on the

Select

button.

The Health Care Record for Sarah Tennant opens.

Creating a new Basic Information Transaction

We are now going to record the Basic Medical Information in Sarah

Tennant’s HCR.

Use the icon to quickly create a basic medical transaction

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As you can see from above the basic medical information sequence is added, next we select the sequence items we require.

Managing Items

In this instance we are going to skip over the first item because we wish to leave it in the file merely as a descriptive title.

1) Ensure the

basic medical information

Item is selected. Press the

Down Cursor

key once.

‘medical history:’ item is now highlighted

2) Press the

Return

key to edit the

medical history:

item. In the

 associated list

Find

box type:

h

 only terms beginning with ‘h’ remain in the list.

Quick Clicks

3) Select the term

hypertension

in the list by clicking on it twice

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 quickly (keep the mouse perfectly still between clicks).

‘hypertension’ added to the medical history item.

4) Click

OK

to close the medical history: item.

Repeating an Item

We wish to record more medical history information for Sarah and to do this another medical history item is required. There is a quick way to do this if an item of the same type already exists in the transaction you are editing. Simply select (not edit) the item which is the same type and press the (=) equals key.

5) The highlight is now on the

surgical history:

item. Press the

Up

Cursor

key once to re-select the

medical history:

item ( or simply click on it once with your mouse)

‘medical history:’ item now highlighted once more.

6) Press the equals key

=

once

A new ‘medical history:’ item is inserted and opens for editing.

7) Double Click on

pneumonia

in the associated term list.

‘pneumonia’ added as a response for this item.

8) Do not close this item yet

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Setting Item Attributes

Each item has a series of settings called attributes, which are in addition to any contents that may have been entered. These perform various functions including how the item and its contents appear on screen, how severe the condition being recorded is

– via a gravity index, moment of occurrence, person responsible and various other information. These are displayed by clicking on the button illustrated when the item is open for editing.

1) The medical history item that contains the term

pneumonia

should

 still be open. If not, open it now for editing and close the associated list box when it appears by clicking on its

Close

button.

‘pneumonia’ text displayed.

2) Click once on the button to display the items attributes.

3) Set the attributes the same way as illustrated in Fig.3:

Medical History Item Attributes

4) When completed click on the

OK

button.

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Item closes and appears in red.

Setting Item Display Mode

You may have noticed above the

Display Mode

box

– which we left on its default setting of

Normal

. Normal display mode shows the Item Name followed by its contents. There are several other ways to display item information

– you can select these by either right clicking with your mouse on the item and selecting

Display Mode

, then select the mode required from the menu, or, click once on the item to select it and then use the short cut keys.

1) Right Click with the mouse on the

medical history:

item for

pneumonia

just created

.

Menu appears

Select the

Display Mode

option

– then select the

Right

option from

 the next menu.

The item contents ‘pneumonia’ stays in view but the item name ‘medical history’ has disappeared.

3) Experiment with other display settings for the same item.

4) Ensure that the item is still selected and press

Ctrl + 3

Item display returns to ‘Right’ mode.

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Viewing Item Attributes

You do not need to open an item for editing to view its attributes. This is only necessary if you wish to

change

their settings. To view, simply select the item by clicking on it once with the mouse and then click on the

Attributes

button on the Item Panel Toolbar

– illustrated on the left.

1) Click once on the

pneumonia

medical history: item to select it.

Click once on the Item Panel Toolbar

Attributes

button.

Attributes for the selected item appear.

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2) Close the Attributes window by clicking once on the button.

Windows closes

Completing the Basic Medical Information

Surgical History:

3) Open the

Surgical history:

item for editing. Select

appendicectomy

from the associated list. Do not close the item yet.

4) Set the

Date of Event

attribute to:

01/07/1992

5) Click on

OK

to close the item.

Family History:

6) There is a history of Heart Disease in the family. Open the

family history:

item and record this by selecting the appropriate term from the associated list and close the item.

Completing the Basic Medical Information

Tobacco:

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7) Open the

tobacco:

item for editing. Select

cigarettes

from the associated list. Then type:

20 p/day

.

8) Click on

OK

to close the item.

Alcohol Consumption:

9) Open the

alcohol consumption:

item for editing. Select

social

from the associated list. Then type:

8 units/week

.

10) Click on

OK

to close the item.

Blood Group:

11) Open the

blood group:

item for editing. Select

A neg

from the associated list.

12) Click on

OK

to close the item.

Recording & Displaying a Problem

Sarah has hypertension and it would be nice to see this instantly when the patient file is opened

– to facilitate this we use the Problem

Panel.

HEALTHone™ copies the contents of the item(s)

problem:

and places it into the Active window of the Problem Panel. Each problem is assigned a START date and - when inactive - an END date. Items that have been given an end date are moved from the Active to Inactive window of the Problem Panel.

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1) Ensure the Item

problem:

is highlighted. Press

Return

to open.

2) Close the associated list and click once on the Term Dictionary (Blue

Book)

Term Dictionary window appears.

3) Type:

Hypert

and then select the term

Hypertension

in the list. Click

OK

The term ‘Hypertension’ is now in the Problem dialogue box.

4) If the Item attributes are not on view click once on the button to reveal them.

5) Click on the START date to activate it and type:

28091978.

Now click

 on

OK

to close the problem item window.

The problem item closes but the contents ‘Hypertension’ does not appear in the Problem Panel

– it must first be validated.

6) Click once on the

Save

button on the Standard Tool Bar and select

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Yes

when prompted to validate the transaction.

‘Hypertension Now Appears in the active Problem Panel.

Recording Non Medication Related Allergies

To record allergies which are not related to medication, such as Gluten,

Cat Hair etc. we use the item allergies

:

Allergic reactions to medication are recorded by using the Drug Module. The technique is fully described in the

Prescription Manager

chapter.

Inserting a new Item

1) Ensure that the item

problem:

is still selected. Now click once on the

Item Selector

button on the Item Panel Toolbar.

Item selector window opens

2) In the Find box type:

all

All items names beginning with ‘all’ are listed.

3) Select the Item

allergies:

in the list. Click

OK

Item ‘allergies:’ is inserted and automatically opens the associated list’

4) Select

cat hair

from the associated list

5) Click on

OK

to close the item.

6) Ensure the

allergies:

item is still highlighted and press the equals key = once

New ‘allergies:’ item created.

7) Select

dog hair

from the associated list.

8) Set the

Display mode

attribute to:

Content Right

9) Click on

OK

to close the item.

10) Ensure the new

allergies:

item is still highlighted and press the equals key

=

once more.

A third ‘allergies:’ item created.

Using the Term Dictionary

The Term Dictionary was mentioned in session three. We use it

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11) Close the associated list box.

12) Click once on the

Term Dictionary Button

(blue book)

Term Dictionary windows opens.

13) Type:

glut

in the

Find

box. Select the term

gluten

in the list and

 then click on the

OK

button.

‘Gluten’ term is inserted as a response.

14) Set the

Display mode

attribute to:

Content Right

That completes the Sarah’s medical information.

Saving a Patient File

Select

Save

on the File Menu and select

Yes

when prompted to validate the transaction.

Select

Close HCR

from the File Menu.

Sarah’s file closes and the patient selector window reappears.

Quitting

HEALTHone™

Select

Exit

on the File Menu. Answer

Yes

when prompted.

HEALTHone™ closes and the desktop reappears.

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Summary Guide

To repeat an item - Select the item to be repeated and press the equals

=

key.

To set item attributes - 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 change the item display mode - Right click on the item to be changed and select the option

Display Mode

from the menu. Now select the display mode required from the submenu’

To view the attributes on an item

-

Select the item required and click once on the attributes button on the HCR Toolbar.

To use a term from the Term Dictionary as a response to an item.

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

Ctrl + T

. Now select the term required in the list.

Own Notes

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