5. Electronic Medical Chart

[0] Chapter Contents

[1] Accessing the Encounter Screen

[2] Patient Information Windows

[3] OSCAR Encounter Menu Bar

[4] CLINICAL MODULES | [5] FORMS | [6] oscarMESSENGER | [7] ENCOUNTER TEMPLATES | [8] MEASUREMENTS

[9] CLINICAL RESOURCES | [10] INTERNET RESOURCES

Table of Contents

[1] Accessing the Encounter Screen

From The Appointment Window

1. Click on the E for Electronic Chart to the right of the patient’s name
2. The Encounter window will pop up with the patient’s name in the top bar
3. Click on white areas (all fields) and type additional information

OR

1. Click the Search tab at the top of the appointment screen
2. Type in last name (or other piece of patient information such as chart number) and click search.
3. Click on the demographic number of the desired patient to pull up the patient's detail record
4. Click on "E-Chart" under the heading "Clinical Modules" in the left-hand navigation bar.

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[2] Patient Information Windows

BACKGROUND INFORMATION

Social & Family History - Other Medications - Medical History - Ongoing Concerns - Reminders

Any information entered in the five boxes at the top of the e-Chart screen will carry forward to subsequent encounter records. All five areas are free typing boxes and the SAVE button at the bottom of the screen saves all information in this window. Just click in the area you want, type and SAVE.

ALLERGIES & PRESCRIPTIONS

With oscarRx you can write prescriptions quickly and easily and keep a record of past and present medications too. The program can also alert you to any allergies the patient has, and informs you if there is a known problem with mixing two different medications.

• The ALLERGIES link will take you to the patient’s oscarRx Allergy Profile. See Chapter 7
• The PRECRIPTIONS link will take you to the main oscarRx page. See Chapter 7

ENCOUNTER NOTES

• All of the notes in the patient’s Electronic Chart are kept as a cumulative report for easy reference.
• Today’s date will appear under the last note and the cursor will fall under the date, in order to begin your note on the encounter.
• If a reason for the encounter was entered in the REASON box when the appointment was booked, it will automatically be inserted beside the date in the encounter note.
• Use templates as a guide to writing up the encounter note for common examinations and disorders. For instructions on how to insert a template into the encounter notes, see below
• If you want to finish the note later, click on SAVE. When the note is completed click on Sign, Save & Exit to save the electronic record, sign your name and exit back to the appointment screen.

Archiving Clinical Notes

When the clinical notes of a file get too long, it slows down the response of the program. OSCAR allows you to split the file and archive in an easy-to-access location. When the file gets to 50%, a ‘SPLIT’ button will appear on the clinical note area and the colour of the % bar turns from green to orange.

When the ‘SPLIT’ button appears in the clinical note area and the % bar has turned from green to orange:

1. Click on the SPLIT button
2. Say YES to the question, “Are you sure you want to split the file?”
3. Click the ENCOUNTER link to view the archived clinical notes

ADJUSTING THE WINDOW VIEW SIZE

On the upper right corner of each patient information window within the e-Chart screen you will see the letters X | S | N | L | F | R to adjust your view of each window of information

• X closes a window if you do not want to use it
• S gives you a small window
• N gives you the normal or default view
• L gives you a large view
• F gives you a full view
• R resets the view to the default

BUTTONS

• SAVE: click when you have partially finished a note and have to leave it temporarily.
• SIGN/SAVE/EXIT: used for a residents to click when they have finished a clinical note. Background of 1st icon on appointment bar turns white.
• VERIFY & SIGN: used for a supervisor to click after reading a clinical note done by a resident or a doctor can use this button for their own clinical notes. Background of 1st icon on appointment bar turns orange.

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[3] OSCAR Encounter Menu Bar

The menu bar to the left of the patient’s Electronic Chart gives you easy access to the other parts of the chart and other resources while you are in this area. Some features add various documents to the patient’s electronic chart, other areas give you access to clinical resources and Internet resources without ever leaving the E-Chart area.

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CLINICAL MODULES 

Master

gives you access to the patient’s Master Demographic window. See Chapter 4

Billing

allows you to bill directly from the encounter screen. See Chapter 6

Prescriptions

allows you to write a prescription directly from this window. See Chapter 7

Consultations

order a consultation visit with the specialist for the patient. See Chapter 10

Immunizations

keep track of the patient’s immunization record. This should be used as an additional resource to oscarPrevention. It contains templates for the immunizations required for different age groups and purposes (ex. Travel clinic vaccinations). These can be filled in and saved for later reference.

Prevention

oscarPrevention keeps track of the most common procedures that help prevent disease in a patient. These include vaccines and common tests (ex. PAP smears). See Chapter 7

• NOTE: if the prevention link is red, the patient is missing information on an important prevention. Clicking on the prevention link will reveal what information is needed.

oscarComm

send e-Documents from one doctor to another. See Chapter 11

Disease Registry

add multiple diagnostic codes to the patients records that can be used for research purposes in the future.

It is important to link your description with the diagnostic code for accurate research data. Text, not linked to a diagnostic code, will not be counted in research reports.

• Type the 1st diagnosis in the top box, then click on the ‘code search’ button to get the correct diagnostic code from the database. Clicking on the number link of the desired diagnostic code will insert it into the box to replace with the diagnostic code.
• You can repeat the above for as many diagnosis you would like to add to the patient’s encounter record, then click on the ‘add’ button to add these to the list on the right.
• You can click on the ‘Resolve’ link beside each encounter diagnois to update the record when a diagnosis has been resolved or ‘Delete’ if an error has been made in entering a diagnosis.

Add Tickler

remind staff to call or book a patient for a ‘repeat procedure’, to pay an unpaid bill, etc. See Chapter 11

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FORMS 

• CURRENT FORMS: to view current forms added to the patients chart click on the arrow beside the word current forms & then click on the form you want to view or add to
• ADD NEW FORM: Click on the arrow for a drop-down menu of the forms available and click on the desired form to add to the patient’s e-Chart. Annual cpx - ALPHA - T2 Diabetes - Mental Health Referral - AR1 & AR2 forms.
• OLD FORMS: when you create a second type of form that has already been created, the current form will move down to OLD FORMS. (ie annual health review in 2001 will move to OLD forms when annual review is created for 2002)

See Chapter 8

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oscarMESSENGER 

OSCARmsg is a secure messaging system within the intranet of the OSCAR clinic and between OSCAR clinic sites. The functions work like many common e-mail programs.

• SEND MSG: Brings you to the main page for composing messages. The message will automatically be linked to the patient whose e-chart you are sending the message from.
• SELECT MESSAGE: Read messages sent to you by other users about this patient.
• ALL MESSAGES: View all messages linked to this patient. See Chapter 11

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ENCOUNTER TEMPLATES 

These templates give you a guide to writing up the encounter note for common examinations and disorders.

1. Click on the arrow beside the word ENCOUNTER TEMPLATES for the drop down menu to access over 250 evidence-based templates from the College of Family Physicians.
2. The template you choose will be inserted into the patient’s eChart under the date and reason for today’s appointment. Modify and add to the template text in order to document the patient's condition

1. Click on the SAVE or SAVE, SIGN & EXIT button to add this to the patient’s e-Chart

For instructions on how to create and add a template to the master list, see Chapter 14- Inserting an Encounter Screen Template

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MEASUREMENTS 

Measurements are used to document vitals and other information about the patient that is commonly measured at each visit (ex. blood pressure, height).

1. Click on the drop-down menu and select the group of measurements you wish to document (ex. the Vital group might contain blood pressure, weight, substance and exercise habits)
2. In the Measurements window, select and follow the desired measuring instruction. For example, if the type of measurement is exercise, you can select either “Yes/No” or “min/week 0-1200”. If you select the former, you just enter Y or N into the value box, if you select the latter, you would enter in a numerical value.

1. After completing the table, click ‘Submit’

• Past measurements can be viewed by clicking the link “Old Measurements”

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CLINICAL RESOURCES 

Resource

takes you to the oscarResource database. See Chapter 13

Documents

view, add or delete this patient’s e-Documents. See Chapter 12

E-Forms

view, add, delete or fill out this patient’s e-Forms. See Chapter 12

View Tickler

view all of the ticklers posted for this patient. From this screen you can add new ticklers, complete or delete old ones, and create tickler reports. See Chapter 11

Calculators

Access 6 different online calculators:

• Body Mass Index
• Coronary Artery (Disease Risk Prediction)
• Osteoporotic Fracture (Average 10-Year Probability)
• Pregnancy Calculator (Conception, End of Trimesters, Due Date)
• Simple Calculator
• General Conversions

Lab Results

menu of all lab results

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INTERNET RESOURCES - Knowledge Search 

You can search the Internet for current medical information about the patient’s problems directly from the ENCOUNTER screen

1. Double clicking on any word in the Encounter screen will put the word in the ‘search for..’ box
2. Click on the drop down menu under the ‘using..’ box to choose your search engine (OSCAR Search, Google, Pubmed, Medline Plus, BNF.org search engines)
3. Click on the GO box to launch into the search engine - another window will pop up with your search on the internet

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