50 Opening John Test`s Health Care Record
Contents
1. 2011Helix Health Ltd 1 Select Exit on the File menu e Close dialogue box appears 2 Click on the Yes button or simply press the RETURN key HEALTHone program closes and you are returned to the desktop HELIX 75 HEALTH 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 P2. 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 _ chronic obstructive airways disease _ dementia _ hypertension 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 Consultation Responsible Your name Date of event Current date and time Speciality general practice Legal Structure Physician general practice Problem None 3 Click on the OK button e 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 HELIX 53 HEALTH Health One Version 7 1 User Manual Copyright 2011Helix Health Ltd ypg SU eeu vn nwy w v uvvun vu vy n vy vee A drug prescription Dr Rory O Driscoll 03 04 99 13 48 FB consultation Dr Rory O Driscoll 01 03700 10 21 drug prescription Dr Rory O Driscoll 03 04 00 13 48 fh consultation Dr John Smith 08 11 0070 Fig 3 2 New Transaction Transaction Status e 1 The style of writing used to display a transaction in the Transaction Panel denotes its status as follows Bold amp Italic not saved or validated Italic saved but not validated Pla
3. S Tolowup T week TTSS Fig 3 6 Transaction Detail Panel Five Items Completed 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 HELIX 73 HEALTH 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 Save transaction 24 x Do you want to save temporarily or validate this transaction Save E Waidate Cancel 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 74 a EEs HEALTH Health One Version 7 1 User Manual Copyright
4. To navigate an associated list 76 a EEs HEALTH 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 HELIX 77 HEALTH
5. 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 ata 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 HEALTHone can define a person as performing one 52 TIS HEALTH or more roles in a practice If this were the case you would select the current role here Usually a person only performs one role i e 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
6. Cult attributes e g the C apy crea responsible doctor will be Adjust colma width the logged on user etc EX Configure 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 1 Open the config tool 2 Click on file gt open gt transaction name File Edit Tools Windows Help The window below opens up Term Ctrl Alt T Configuration tool Transaction name Sequence Shitt F4 7 Fiteis eerie a zi G suliat Aggregate shift F5 GC case en viskat heme Leadin oti Show all terme seating 9 dug piesoritions Associated list Ctr aAlt 4 E Permanent list Ctri Alt P Grid Ctrl G Transaction name obstetnes lab Transaction name consultation radiology ansultation by appointment consuliation by telephot onsullation by teleohone speciaized exarrinatio orisullart s opinion health check up The first three consultation types in the list are those available in the patient selector of HEALTHone 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 HELIX 55 HEALTH Health One Version 7 1 User Manual Copyright 2011Helix Health Ltd
7. Selected ransaction name 2 crud orescurbo Remove icon 2 vaccination vist al home Define icon You can also change the icon associated with any particular transaction name by right clicking on the name and choosing the change icon option consultation by talephona specialized examination heath check up Henry epeil z repot payment vik al home G 8 RB Q gS E f 8 amp The Item Selector HEALTHone items are accessed via the Item Selector window this displays a dictionary of all the items in HEALTHone Clicking on the Item Selector Button on the Item Panel Toolbar illustrated below will display the selector window see fig 3 3 Administrative transaction Billing 0 00 Action plan Appointment oM MA BE Bat Inserting Items 56 TS HEALTH Health One Version 7 1 User Manual Copyright 2011Helix Health Ltd Fig 3 3 Item Selector Window Item Selector x To locate an item type here Find SS aes T date off work Refresh button Active when Synchronous is not selected date of admis Note If the F date of dechar MI Synchronous F date of last contact e i date of case conference Item option is 3 pai ot accident Dictionary selected be low Bde of ath Mo list currently the list will 2 ae orana INPI unsorted stri el reduce to Rexnocted dale d delivery EDD display only 7 date ae matching items Brae c aarri
8. Transactions amp 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 HEALTHone program Starting the Program and Logging In Start the HEALTHone program and login e HEALTHone opens and the Patient selector window appears If you are unsure about starting HEALTHone 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 e 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 e The Health Care Record HCR for John Test opens 50 TiS HEALTH l Health One Version 7 1 User Manual Copyright 2011Helix Health Ltd 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 E the Transaction Panel Toolbar See refe
9. does not have an associated list 70 TS ey HEALTH Health One Version 7 1 User Manual Copyright 2011Helix Health Ltd 4 Use the Item Dictionary to enter the term sebaceous cyst asa 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 sebaceous cyst 2 2cm assessment sebaceous cyst back of neck Fig 3 5 Transaction Detail Panel 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 HELIX 71 HEALTH 3 Select the Item plan of action and click once on the OK button e 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 e The sub list 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
10. ee 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 Term Dictionary Button Associated Permanent Book Icon List Button List Button 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 It s easier there is no need to remember the spelling of complicated medical terminology HELIX 61 HEALTH 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 e Term Selector Window appears 2 Ensure that only the Leading and Synchronous options are checked 3 Type nec e List reduces to only terms beginning with nec 4 Select the term neck pain 5 Click on the OK button e Neck pain inserted as a response and the selector window closes The Permanent List John Test describes the pain as acute T
11. he Item Attributes panel click on the illustrated button once Click again to close The Item box should now appear as in Fig 3 4 HELIX 59 HEALTH Health One Version 7 1 User Manual Copyright 2011Helix Health Ltd subjective symptoms Fig 3 4 The Subjective Symptoms Dialogue Box 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 of line Type new e 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 e Text deleted 60 TiS HEALTH 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 degr
12. ic respiratory 2 cardiovascular A circulation Zm i cow 2 He I Match case M Sorted VL 3 V Synchronous 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 64 Te HEALTH The History Option Box To use the History box you need to understand how the list is structured List Structure Icon used to indicate that a term has alist of its own 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 HELIX 65 HEALTH Health One Version 7 1 User Manual Copyright 2011Helix Health Ltd common au pain Dl lump Dl tired all the time cough sore throat headache oe vomiting sat pets pain on swallowing mDacK pain swallowing difficulty dy imitation i haa Pi N kg History box notation mo 0 common 1 sore throat Level No 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 His
13. in saved and validated Bold previously validated transaction that has since been modified but not revalidated 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 54 TiS HEALTH Health One Version 7 1 User Manual Copyright 2011Helix Health Ltd surname firstname Patient ags patient cale GMS number ret dete of bith addiess of Once you click on one of BURKE MARGARET 39 PP 06 04 1357 45 MAIN ion types i BURKE SANDRA 24 14 10 1932 14 MAIN the transaction types in the DALY PATRICK 3 GMS 78272100 27 10 2033 UPPER M list a new transaction will 7a Tr z E CUN immediately be created LEAHY Ji E Sect ao f 04209 2044 THE BELLI With all pay Do on PETEHSUN Mx Delete ao BB 12 11 1952 UPPER 5 k I TEST FI i 6 11205 1993 FORREST attributes e g the voun ofl mer iC 2070371939 LPPERC responsible doctor will be C3 Export Note from the patient selector right click and choose the item the logged on user etc D ew oN new transactio You have Q patients From same Famiy soveral options P Once you click on one of Non Tanadan R uan M amp s the transaction types in the Send the HCR to the support F wit at home crl H an D ba aona 3 EA im iate crea Rebuld the patient index drug prescriptions Ctrl B F J pee with all the default Show deleted patient Ctrlear z others
14. n 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 HELIX 69 HEALTH A One versic J Jal Copyrigr 4 Click on the Close button to close the Associated List dialogue box or press Esc 5 Click once on the Term Dictionary Button e Term dictionary now appears 6 Type seb in the Find box and select the term sebaceous cyst click on OK e Term sebaceous cyst entered as a response and the dictionary closes e 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 subjective symptoms neck pain lump 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
15. naleni H as you type Click Sorted X Carcel Hep to display the Click Match listin Case to P Match case Sorted Alphanumeric locate items doe Peach Order ii by exactly blige i how and what ne has been Click Leading to locate items Click Synchronous to typedinthe by comparing what has been automatically reduce the list Find box typed in the Find box to only to display only matching the letters at the beginning of items the Item Name Uncheck to locate by an occurrence anywhere in the Item Name When Synchronous is not selected matching items are only filtered when the Refresh button is dicked 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 HELIX HEALTH 57 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 e 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 Synchrono
16. o record this we use the Permanent List 1 Click once on the Permanent List Button e 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 62 TS HEALTH Selecting Deleting a Term A term selected from one of the lists is treated by HEALTHone asa 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 e The ENTIRE term 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 e 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 e Associated List dialogue box appears HELIX 63 HEALTH Health One Version 7 1 User Manual Copyright 2011Helix Health Ltd Associated List Selector Ed Find Iyp me a K2 Associated Permanent Select a term Ol paediatric symptoms Ul Zflu like illness spinal pain locomotor Fears nose throat opt
17. rence sheet e The Transaction Properties dialogue box appears see Fig 3 1 Transaction properties Institution Type Name Responsible Date of event Speciality Legal structure Comment Health approach Problem Contact X consultation Dr John Smith 25 02 2006 jhe general practice x Physician Green Park Medical Cente x oe alcoholism _ Alzheimer s disease chronic obstructive airways disease hypertension Access rights Export protected I Display protected Fig 3 1 Transaction Properties Dialogue Box Transaction Attributes In the previous session we mentioned that each transaction has a set of HELIX HEALTH 51 attributes Some of those are specified at creation time in the Transaction Properties dialogue box above Type This attribute designates the type of transaction In General Practice the most common types would be Contact and Basic Medical Information Institution admission Institution discharge Department admission Department discharge Basic medical information Summar Type Name Currently this Name attribute is used c only for Contact Beponsible yarara visit at home type transactions It Date of event drug prescription defines the reason obstetrics for the contact Speciality lab radiology consultation by telephone specialized examination _ Responsible Specifies the name of the
18. term excision is selected Press the Return key e The sub list 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 e Anew 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 e The term follow up is used as a response and its sub list 72 a EEs HEALTH Health One Version 7 1 User Manual Copyright 2011Helix Health Ltd appears 3 Select the term 1 week in the sub list and press Return 4 Click OK to close the plan of action dialogue box e Your completed transaction should now appear as in Fig 3 6 subjective symptoms neck pain lump objective findings sebaceous cyst 2x 2cm assessment sebaceous cyst back of neck plan of action excision shelled out successfully planofaction
19. tory 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 History 1 sore throat 1 sore throat Navigating the List 66 TiS HEALTH 1 Click once on the term common to select it and then press the Right Cursor Key once e Sub List for common term appears and History Box displays O 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 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 HELIX 67 HEALTH 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 bo
20. us option e Refresh button activates 9 Type in capitals IC e Nothing happens 10 Click once on the Refresh button e All Items that contain the letters IC together anywhere in their name are displayed 11 Check the Synchronous option e Refresh Button de activates screen stays the same because Synchronous is active and filtering on IC 12 Check the Match Case option e 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 58 TiS HEALTH Match Case Unchecked Leading Checked Sorted Unchecked Synchronous Checked We need to locate the Item subjective symptoms 1 Delete the IC in the Find box and type su e 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 e 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 e Associated List box closes and Subjective Symptoms dialogue box is active Showing Hiding the Item Attributes Panel 1 To show or hide t
21. x 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 e 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 68 TS HEALTH 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 o
Download Pdf Manuals
Related Search