A web based Electronic Medical Records (EMR) & Medical practice Management system.
The software designed to be develop can be an online web based Medical Practice Management system designed to computerize the clinic and provide a seam less integration of its various processes.
The application should facilitate input, storage, transfer and retrieval of medical information inside a practice and enables interfacing with other data providers beyond your practice.
The application form aims to expedite record keeping processes and enable doctors to retrieve and input Patient Data, Medical Data, Analysis Reports etc., anywhere and anytime from the PC. Also the application form should provide electronic capabilities for routine tasks linked to clinical data( Such as for example Patient Registration, Search for Patient Transcription, imaging, Messaging and Prescription writing, Staging of Cancer, Suggestion of Relevant Regimens based on Staging, in addition to a wireless point-of-care solution for Doctors in the examination room.
EMR Workflow
Modules Overview:
1. Patient Registration and Appointment Scheduling
Patient will undoubtedly be registered with the system by way of a Nurse/ front office / doctor.
2. Patient Demographics
Capture all of the patient preliminary details, such as for example
o Personal Information
o Correspondence details
o History of the Patient
o Social Background
o Insurance Details
o Family History
o Family Medical History
o Allergies and Operations
o Education details
3. Patient Chart
Patient chart includes complaints, diagnosis, vitals, prescribed tests, current medications, drug allergies, past surgeries and clinical reminders details will be displayed. Also patient name, sex, age, date of last visit and patient related menu will undoubtedly be displayed. An individual related menu option includes chart, subjective, plan, order, assessment, others, super bill and mark as seen.
4. Physical Examination
Set of items for a fresh Physical Exam will be displayed and automagically General details form will undoubtedly be displayed for capturing the facts. New Physical Exam can be made for a patient includes general details, eyes, ears, etc details list will be displayed.
5. Review of System
If any Clinical Trials information available, the doctor refers to it including the drug information Charts, Lab Reports, Chemo Order generation, Clinical Trials Info.
Review all the previous hospitalization, reports prior to starting the treatment.
6. Diagnosis, Staging and Chemotherapy
The doctor uses the proposed software from the main point where he diagnoses the patient and determines the cancer type. The software will undoubtedly be used from then onwards as under:
o ICD Code Master
o Diagnosis Process predicated on ICD
o Staging
o Stage Grouping
o Medicine for Chemotherapy
o Chemo Order Generation
o Flow Sheet for Chemo Cycle
Based on all the above inputs the doctor diagnoses the individual and understands the problem. This results in determining the Cancer Stage.
In case there has been and Clinical Trials information the doctor refers to it including the drug information Charts, Lab Reports, Chemo Order generation, Clinical Trials Info. Predicated on all this information the doctor writes a prescription and doctor's note and enter the relevant details with the charge capture form.
In case the patient requires Chemotherapy the doctor schedules another appointment for him with a nurse and the relevant procedures must be followed.
7. E-Prescription
Displays all previous prescriptions (if exists) with date and edit links for a particular patient. If no prescription exists, i.e., the individual is really a new patient doctor will generate a new prescription.
8. Doctor Notes
Doctor can able to enter notes regarding patient, after physical testing and diagnosis. And a doctor/nurse may also view the set of all doctor notes created for a patient
9. Nurses Notes
List of regimens prescribed to an individual by the doctor will undoubtedly be displayed to a nurse to select regimen for capturing other details. Nurses can provide other treatment apart from regimen treatment by phone.
The nurse initiates the chemotherapy process and maintains a detail of medication and IV access for the patient. This technique ends with Charge Capture predicated on ICD Codes and subsequent Scheduling for next appointment.
o Nurse will get the relevant patient chart.
o Views the Chemo Schedule and description.
o Updates the chemo order sheet and creates the nurses notes.
o Closes the 'chemo day' after the chemo has been completed.
o Views the nurse's report/notes.
o Closes the 'Chemo' after all the chemo days have been closed
10. Laboratory Management
This is used to capture tests information under special diagnosis. If tests are already prescribed for a patient by a doctor, then page will be displayed with existing data and can be captured other new tests otherwise new page will undoubtedly be displayed for input, new prescribed tests will be captured and shown back with captured data.
11. Others
o Demo Project Codes
o Other Scanned Documents
o Spell checker
o Audit Trail
o Phone Call board
12. Billing Management
The software shall not cope with the billing module and if required shall only have an integration with the prevailing Billing Management System
13. Reports
o Patient Registrations
o Patient Visits
o Diagnosis-Location
o Diagnosis-Cancer
o Doctor Visits
The above reports will be presented in a graphical representation (Bar and pie chart) for the respective data captured in the application.
Key Features:
1) Patient Registration & Appointment Scheduling
2) Patient Demographics
3) Patient Chart
4) Physical Examination
5) Review Of Systems
6) MRI
7) HPI
8) Diagnosis, Cancer Staging and Chemotherapy
9) E-Prescription
10) Doctor Notes
11) Nurses Notes
12) Laboratory Management
13) Others
14) Billing Management
15) Reports
16) Admin Module
1) Patient Registration & Appointment Scheduling:
Patient registration can be done in two ways:
1. Through Appointment Scheduling
2. Registration by visit.
Patient will undoubtedly be registered with the system by way of a Nurse/ front office / doctor. If a patient booked a scheduled appointment on a specific date, leading office will have a provision to track the individual physical arrival status.
2) Patient Demographics
Capture all the patient preliminary details, such as for example
The sub functionalities of this feature are the following:
a. Personal details
b. Insurance Details
c. Social history details.
d. Medical history details.
e. Family history details.
f. Family health background details.
g. Surgical history details.
h. Hospitalization details.
i. Correspondence details.
j. Chief complaint(s) details.
k. Drug allergies details.
l. Current medication(s) details.
m. Discontinued medication(s) details.
n. Vitals details will undoubtedly be captured and may update date wise.
o. Women Only - Women related information will be captured (like Amount of
Pregnancies and Number of Children born etc). This is exclusively for women only.
p. HIPAA - A provision to upload HIPAA related docs.
Update existing details.
3) Patient Chart
Patient chart includes complaints, diagnosis, vitals, prescribed tests, current medications, drug allergies, past surgeries and clinical reminders details will undoubtedly be displayed. Also patient name, sex, age, date of last visit and patient related menu will undoubtedly be displayed. A patient related menu option includes chart, subjective, plan, order, assessment, others, super bill and mark as seen.
a. Display Patient Chart
b. Display, Add and Modify Complaints details
c. Display, Add and Modify Diagnosis details
d. Display, Add and Modify Vitals details
e. Display, Add and Modify Prescribed Tests details
f. Display, Add and Modify Current Medications details
g. Display, Add and Modify Drug Allergies details
h. Displaying different details of a patient as a report
i. Display, Add and Modify Past Surgeries details
j. Display, Add and Modify Clinical Reminders details
k. Display, Add and Modify Flow sheet details
l. Display, Add and Modify Template for referral note details
m. Display, Add and Modify Template for letter details
n. Display, Add and Modify Tumor Marker details
o. Display, Add and Modify PT/INR details
p. Display, Add and Modify Diagnostic test details
4) Physical Examination
Set of items for a New Physical Exam will be displayed and by default General details form will undoubtedly be displayed for capturing the facts. New Physical Exam could be made for a patient includes general details, eyes, ears, etc details list will be displayed. . Physical Exam Gen ID will be generated.
i. The sub functionalities of this feature are:
a. General details
b. Central Line details
c. Skin details
d. Head and Face details
e. Eyes details
f. Ears details
g. Nose and Nasopharynx details
h. Neck details
i. Lymph Nodes details
j. Musculoskeletal Details
k. Genitalia
l. Rectal
m. Breast
n. Cardiovascular details
o. Respiratory details
p. Abdomen details
q. Extremities details
r. Neurological details
ii. Display set of report(s) created for a specific patient date wise
iii. Display individual report.
iv. Update existing report details.
v. Delete existing report(s) details.
5) Review of System
i. Capture the next details
a. General details
b. Eyes details
c. Cardiovascular details
d. Genitourinary details
e. Musculoskeletal details
f. Skin details
g. Psychiatric details
h. Endocrine details
i. Respiratory details
j. Ear, Nose, Mouth and Throat details
k. Gastrointestinal details
l. Breasts details
m. Neurological details
n. Hematological/Lymphatic details
o. Chest Details
ii. Display list of report(s) created for a specific patient date wise
iii. Display individual report.
iv. Update existing report details.
iv. Delete existing report(s) details.
6) MRI Details
i. Capture MRI details
ii. Display set of report(s) created for a particular patient date wise
iii. Display individual report.
iv. Update existing report details.
iv. Delete existing report(s) details.
7) HPI
a. General HPI or HPI details and can view past HPI details date wise.
b. Lung Cancer HPI details.
c. Colon HPI details.
d. Breast HPI details.
8) Diagnosis, Cancer Staging and Chemotherapy
The physician uses the proposed software from the main point where he diagnoses the individual and determines the cancer type. The program will be used from then onwards as under:
o ICD Code Master
o Diagnosis Process predicated on ICD
o Staging
o Stage Grouping
o Medicine for Chemotherapy
o Chemo Order Generation
o Flow Sheet for Chemo Cycle
Based on all the above inputs the physician diagnoses the patient and understands the issue. This results in determining the Cancer Stage.
In case there has been any Clinical Trials information the doctor refers to it like the drug information Charts, Lab Reports, Chemo Order generation, Clinical Trials Info. Predicated on all this information the doctor writes a prescription and doctor's note and enter the relevant details with the charge capture form.
In case the patient requires Chemotherapy the doctor schedules another appointment for him with a nurse and the relevant procedures must be followed.
a. Doctors can view diagnosis report.
b. Doctors can make diagnosis by selecting ICD Code and Disease Name.
c. Capture ICD Code, histology details, histological grade and residual tumor
grade details.
d. Define the stage and capture stage details.
e. Doctors can see all the existing regimens.
f. Doctors can create blank regimen or related regimens with cancer type or
ICD Code and capture the details of regimen.
9) E-Prescription
Displays all previous prescriptions (if exists) with date and edit links for a particular patient. If no prescription exists, i.e., the physician will create a fresh prescription.
a. Doctors can maintain common prescription list.
b. Doctors can maintain common drug(s) list.
c. Doctor can generate a new prescription or generate prescription with an
existing common prescription.
d. Doctor can update or delete a preexisting prescription(s) for a specific patient.
e. Doctor can have a preview, print and fax the complete prescription.
f. Doctor will have glance of chief complaints, cancer type, stage and current
medication(s) and discontinued medication(s) details during giving a
new prescription or updating prescription.
g. Doctor will have a facility search for selecting the drug(s).
10) Doctor Notes
Doctor can able to enter notes regarding patient, after physical testing and diagnosis. And a doctor/nurse may also view the set of all doctor notes created for a patient
a. Doctors have a facility to see list of doctor notes as a report created for a
particular patient.
b. Doctors have a facility to view particular doctor note created for a particular
patient
c. Doctors can update exiting doctor note designed for a particular patient.
d. Doctors can delete exiting doctor notes created for a particular patient.
e. Doctors can create new note on patient last visits containing the details of
HPI, history and plan.
f. Doctor can create a fresh note with an existing doctor note for a particular
patient.
g. Doctor can have facility to search referral doctors list and will add them to
doctor note.
h. Displaying different details of a patient as a report
i. Including different information on a patient in a particular doctor note
j. Modifying different details of a patient in a specific doctor note
k. Doctor's note could be print and fax.
11) Nurse Notes
Set of regimens prescribed to an individual by the doctor will undoubtedly be displayed to a nurse, to choose regimen for capturing other details. Nurses can provide other treatment aside from regimen treatment by phone.
The nurse initiates the chemotherapy process and maintains a detail of medication and IV access for the individual. This technique ends with Charge Capture based on ICD Codes and subsequent Scheduling for next appointment.
1) Clicks on the individual ID to achieve the patient chart relevant to the nurse.
2) Views the Chemo Schedule and description.
3) Updates the chemo order sheet and creates the nurses notes.
4) Closes the 'chemo day' following the chemo has been completed.
5) Views the nurse's report/notes.
Closes Click here ' after all of the chemo days have been closed
a. Nurse can view all the regimens prescribed by the physician to a patient.
b. Nurse can select regimen to see treatment schedule for that one
regimen to a patient.
c. Nurse can decide on a day in treatment schedule cycle and required data will undoubtedly be
captured for regimen.
d. Nurse can make a note under Non ChemoMedicine, Chemotherapy, Pump,
Phlebotomy, Antibiotic, Hydration, Hormone Injection, Antiemetics, Laboratory
and Paracentesis.
e. Nurse can close or open a day in a cycle for particular regimen.
f. Nurse can close or open a cycle or chemo cycle for particular regimen.
g. Nurses can provide non chemo other medicine at hospital or on phone.
h. Nurse can view cycle are accountable to a particular regimen for a specific patient.
12) Laboratory Management
This is used to capture tests information under special diagnosis. If tests already are prescribed for a patient by a doctor, then page will undoubtedly be displayed with existing data and will be captured other new tests, otherwise new page will be displayed for input, new prescribed tests will undoubtedly be captured and shown back with captured data.
a. Doctors can order In-house or Out-House lab tests under Laboratory, Special
Diagnosis, CT scan, Radiology, Respiratory, Physiotherapy, Nuclear Meds,
Ultrasound and Miscellaneous Orders for a particular patient.
b. Doctors can cancel the tests that have been ordered previously for a specific
patient.
c. Doctors can view pending, completed and seen tests for a particular patient.
d. Doctors or Lab Person can upload In-house or Out-house tests information
which were undergone present or past by the patient.
e. Clinical Reminders can be captured, modified and displayed.
f. Doctor or Lab person can view today's studies by patient name or test name.
13) Others:
a. Capture Patient Other Scanned documents & Modify or Edit Patient Other Scanned documents
b. Demo Project Codes - Here the diagnosis related data will undoubtedly be mapped with the Insurance in line with the given gcodes
c. Capture, Modify and Display Patient Educational information on diseases
d. Capture, Modify and Display Patient Medication log
e. Capture, Modify and Display Pathology
f. Display Patient Diagnosis flow sheet according to the patient visits.
g. Capture, Modify and Display Bone marrow biopsy
h. Capture, Modify and Display Phlebotomy
i. Capture, Modify and Display Paracentesis
j. Phone Call board - Where the nurse/front office/doctor can attend and prescribe the right solution to a patient through phone call. All these details will be captured.
k. Mark as Seen - Doctor can mark the patient consultation status as seen for your day.
l. Spell Checker - Using this feature, the user can perform the spell talk with the related forms.
m. Audi trail - Captures Doctor Visits on patient including Ip, visit time stamp and navigation info on patient records.
14) Billing Management
The system should provide the billing information, which needs to be integrated with the 3rd party billing software.
Capture the following details
a. Primary focus of visit charges
b. Practice Guideline Adherence charges.
c. Current Disease State charges.
d. Office services charges.
e. Out patient initial consultation charges.
f. Prolonged services charges.
g. Miscellaneous charges.
h. Non-chemotherapy Injections charges.
i. Chemotherapy Injections charges.
j. Non-chemotherapy drugs charges.
k. Chemo Administration charges.
l. Chemotherapy drugs charges.
m. Laboratory services charges.
n. New Consultation charges.
o. Confirmatory Consultation charges.
p. Emergency Department Service charges.
q. Initial Hospital Care charges.
r. Initial Observation Care 8 hrs charges.
t. Subsequent Hospital Care charges.
u. Follow up Consultation charges.
v. Chemo drug charges will be automatically put into the super bill.
ii. Update existing details.
iii. Display super bill for all charges.
Note: The program shall not deal with the billing module and if required shall only have an integration with the existing Billing Management System. It'll facilitate all of the required inputs/information to the billing software.
15) Reports
a. Patient Registrations
b. Patient Visits
c. Diagnosis-Location
d. Diagnosis-Cancer
e. Doctor Visits
The above reports will undoubtedly be presented in a graphical representation (Bar and pie chart) for the respective data captured in the application.
16) Admin Control Panel
I. Office Admin details
1. Capture the following details
a. Appointment Type details.
Appointment type details include appointment type and description will be
captured.
b. Clinic details.
Clinic details include clinic name, street line1, street line2, city, state, zip, country,
work phone along with other phone will be captured.
c. Pharmacy details.
Pharmacy details include pharmacy name, contact person, address1, address2, zip,
phone1, phone2, email, fax1, fax2, registration id, open time, close time and round
clock will undoubtedly be captured.
d. Holiday details.
Holiday details include holiday name, start date, end date, day, recursive and
creation date will undoubtedly be captured.
e. Employee category details.
Employee Category details include employee category name and remarks will undoubtedly be
captured.
f. Employee Master details.
Employee Master details include salutation, title, first name, middle name, last
name, date of birth, sex, ssn, marital status, photograph, address1, address2,
city, state, zip, email, home, work, other phone, cell, username, password, role,
superior and employee category will be captured.
g. Custom Scheduler details.
Custom Scheduler details include clinic name, start time, end time, default interval and custom interval will be captured.
h. Employee Leave/Vacation details.
Leave details include employee name, from date, to date, start time and end time will be captured.
i. Referral doctor details.
Referral Doctor Details include doctor name, hospital name, hospital phone, doctor phone and classification will be captured.
j. Doctor clinic details.
Doctor Clinic details include clinic name, employee name, from date time, up to now time, recursive date, start date, from morning, to morning, recurrent day, end date and terminated will undoubtedly be captured.
2. Update existing details.
3. Delete the prevailing details
II. Diagnosis Management details
1. Capture the following details
a. Residual Tumor Grade details.
b. Histological details.
c. Histological Grade details.
d. ICD Code details.
e. ICD Histology details.
2. Update existing details.
3. Delete the existing details
III. Staging Treatment details
1. Capture the next details
a. Chemo drug code details.
b. Antiemetics details.
c. TNM details.
d. Regimen details.
e. Admin code details.
f. Drug code details.
2. Update existing details.
3. Delete the existing details
IV. Orders details
1. Capture the following details
a. MRI Part details.
b. Test details.
2. Update existing details.
3. Delete the existing details
V. Super Bill details
1. Capture the next details
a. Super Bill Header details.
b. Super Bill Data details.
2. Update existing details.
3. Delete the existing details
VI. Flow sheet details
1. Capture the next details
a. Flow sheet details.
2. Update existing details.
3. Delete the existing details
VII. Demo Project
1. Capture the following details
a. Section details.
b. Cancer Type details.
c. GCode details.
d. ICD & GCode mapping details.
2. Update existing details.
3. Delete the existing details