Instructions for Use

To Display the Patient Folder Module

Click , or select Patient Folder from the Main Menu.

You can also double-click a patient in either the Current or Discharge List within the Patient Administration module.

About the Patient Folder Module

The Patient Folder module is organized in the same way as a medical notebook. The tabs displayed down the right-hand side of the notebook represent the different sections of the notebook. To open a particular section, click the corresponding section tab. The tabs displayed at the bottom of some pages of the record indicate that the section contains multiple pages. To open a particular page, click the corresponding page tab. Depending on the options installed by your system administrator, any of the following sections may be available:

N o t e

The name of some of these sections may be different in your configuration

(see “Overall Configuration of the Patient Folder” on page 41 in the Configu-

ration chapter).

Section:

Personal Data

Admission

Med. History

Diagnoses

Contents:

Sex, Nationality, and birth place.

Date of admission, admitting department, and reason for admission.

Former medical conditions and illness.

Main and secondary diagnoses.

3-2 Using the Patient Folder Module

Procedures

Health State

SAPS

Nursing

Cost Capture

Operations and treatment procedures previously performed. (This feature is not available in the United

States of America)

Daily health state of the patient.

The SAPS II scoring system provides a quick overview of a patient's state and survival chances on entering the unit.

Nursing attention received by the patient.

Performance gathering and daily TISS number accrued by the patient.

Discharge Discharge date and time, condition, and discharge diagnosis.

Additional Notes Two pages for keeping freehand notes.

User Pages Two pages for data on specific topics, either as fields

for entering data, or pull-down lists. See “Configuration for the User Definable Sections” on page 70 of the

Configuration chapter.

The following figure shows the functional areas of the Patient Folder module.

From this screen, you can go to any of the different sections by clicking the appropriate section tab.

Patient Folder Module

Using the Patient Folder Module 3-3

General features of the Patient Folder module are as follows:

• Each section may be a single page, for example, Diagnoses, or may contain several pages, for example, Personal data. When a section contains multiple pages, the first page is referred to as the main page.

• Navigate through the module by clicking section tabs and page tabs or arrows at the bottom of the screen.

• Enter data into a field by placing the cursor in that field and then either type the desired entry or select from a preconfigured list. Check buttons are also available in some screens; simply click them on or off as appropriate.

• Some pages may contain fields that can be defined by the system administrator. For more information about these fields, see your system administrator.

To Save Module Data

After entering data, either select another module or another page. The data on the selected page is automatically saved.

Data is also saved if you log off, or if the automatic log off locks the

Documentation Center.

Data in dialog boxes is saved as soon as you press [OK]

The rest of this chapter describes the contents each section in detail. As many of the fields can be configured by your system administrator, only the default settings are described. For more information about the configuration of these fields, see your system administrator.

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The actual setup of the sections as well as their visibility is configurable and may be different from the default configuration, described in this document.

3-4 Using the Patient Folder Module