Smart Electronic Medical Records
Patient’s Profile
(Extended Problem List)
This is displayed on the left sidebar of the clinical notes
Problem List
- Current Problems
- Past History
- Surgical History/Procedures
- Family History
- Social History
- Smoking
- Alcohol
- Exercise
- Diet
- Pregnancy
- Obstetric History
- Menstrual History
Disease Management / Tools
- Goals
- Care plans
- Pathways
- Management Programs
- Operations
Add new profile items
- Click on the [+ Add] button at the top of the profile
- Select the appropriate category
- Add the description
- Press [Enter] to code (if the background is orange)
- Add responses to other questions (specific to each profile category)
- Select a colour when you wish to highlight the item
- Set the privacy flag when you wish to restrict access
- Enter additional comments
- Click on a new Category to Save and Add another item
- Click [OK] when finished
Colour
Use colour to highlight items
Privacy Flags
- Private
- Do not include in referrals
- e.g. depression
- Hidden
- Display as blank in profile until clicked on
- extra sensitive, hide from onlookers
- e.g. termination
- Author
- Only visible to the original author
- Profession
- Only visible to other staff of the same occupation
- Organisation
- Visible only to staff who work for the same organisation as the author
A break-glass option is available to view private records which will leave an audit trail of the activity
Menu Options
Right-click on a profile items for options
Edit
- Brings up the editor to view or update details
Remove
- Delete the item
Move
- Move between Current Problem (Active), Past History (Inactive or completed event) and Surgical History or Procedure.
Search Old Notes
- Filter the old notes to display consultations that refer to this item
View consults
- Filter and display consultations that refer to this item in the side view
Promote
- Move higher in the profile display
Demote
- Move lower in the profile display
