This is the center of FreeMED's Electronic Medical Record (EMR). The display of the patient's chart is highly configurable in FreeMED. Health care providers, administrative staff, clerical staff and billing staff members can choose to view the sections of the patient's chart that are of interest to them. To configure the desired view of the record, one would click on Patients --> Configure on the menu bar. When you are in the first page of the configuration screen, click on this %%"Configure" link,manage,configure%% to see the next help screen.
On this patient's front sheet you will see separate sections of the chart. These sections are named modules. The modules can be arranged in one, two or three rows and the position of each module on the chart can be chosen by the individual user.
The amount of information shown on the front sheet can also be chosen. One can display one to ten descriptions of progress notes on the front sheet for instance.
Description of modules:
- Patient Information: If one clicks on "Modify", you will be taken to another screen with six tabbed sections named "Primary Information", "Contact", Personal", "Physician", "Medical" and "Notes". The information that needs to be entered is self-explanatory.
If you prefer to see the entire registration screen on one page rather than the six tabbed sections, click on Main -> Administration Menu -> System Configuration and then set "Fold Multipage Forms?" to No.
- Patient Appointments: If you click on "Add", you will be taken to another screen where you can book an appointment. If you click on "View/Manage", you will see all of the appointment that the patient has. From here you can deletete an appointment or move it. If you click on "View Today" you will see the details of today's appointment.
- Photo Id: If you would like to have pictures of your patients in FreeMED, scan the photo that is on the patient's divers license and then click on "Update" to add it to the record. You can change the photograph in the same manner. You can also click on "Remove" to delete the picture.
- Progress Notes: Click on View/Manage to see descriptions of all of the progress notes. If a patient has many progress notes and
you have configered FreeMED to display the last five progress notes, then in order to see all the progress notes descriptions click on
View/Manage.
Under the "Action" header, you can edit the progress note (the green S shaped symbol), you can delete the note (the red x symbol), view the
note (the magnifying glass symbol), lock the note (lock symbol), print it or fax it (printer symbol) and annotate the note. The note
will automatically be annotated when it is faxed. It will then display when the note was sent and to which phone number it was faxed.
Click on Add to write a new progress note in a new page.
- Letters: These are letters that have been sent to other providers. If you happen to have the Letters Box Module, the letters to
physicans can be written here or scanned in here. If you click on View/Manage you will see that you can "PRINT" it,"MOD"ify the
letter, "DEL"ete it or "LOCK" it so that it cannot be altered.
Under the "Action" header, you can edit the letter (the green S shaped symbol), you can delete the letter (the red x symbol), view the
letter (the magnifying glass symbol), lock the letter (lock symbol), print it or fax it (printer symbol) and annotate the letter. The letter
will automatically be annotated when it faxed and display when the letter was sent and to which phone number it was faxed.
You can also click on "ADD" to write a new letter.
- Patient Correspondence: These are letters that have been sent to the patient. If you click on View/Manage you will see that you can "MOD"ify the letter, "DEL"ete it or lock it so that it cannot be altered. You can also click on "ADD" to write a new letter.
- Medications: If you click on 'View/Manage", you will see the list of all the medications that the patient is taking. You can then
delete a medication, add a medication or change the dose. If you click on "Review All", you can see the list of all of the medications. If
the dosage and the list is correct, then if you click on "Return to Menu", the date when the medications were reviewed will change to today's
date. If you click on "Add", you will have the ability to add a number of medications at once. If the medication has been entered
previously, you will see it as you start to write it. If the medication has not been entered previously, then just by typing it, it will be
available to choose the next time you enter a medication. Be careful to spell the name of the drug correctly. Misspelled names of drugs
cannot be removed. Also be sure to write only the name of the drug. Do not write ASA 325 mg. The dosage of the drug is chosen on the second
line or can be written, ie. 325 mg tablet. The Method of Intake can be also be chosen on the third line or it can be written, ie Take two
tablets every four hours as needed for discomfort.
- Allergies: If you click on 'View/Manage", you will see the list of all the allergies that the patient has. Here you can
"MOD"ify an entry or "DEL"ete it.
You can "Add" entries.
You can "Review All" to review the patient's allergies and enter the date that the allergies were reviewed. To do this, click on
"Review All" -> "RETURN TO MENU". This will update the date that the allergies list was reviewed.
Under the "Action" header, you can edit an allergy entry (green S shaped symbol), remove an entry (red x symbol) and annotate the entry.
- Prescription: If you click on 'View/Manage", you will see the list of all the
prescriptions that have been written for the patient. Although you will see a "VIEW" button, you
cannot vew the prescriptions this way. You can, however, "MOD"ify it, "DEL"ete it, and "LOCK"
the prescription.
You can "ADD" a prescription from this view or you can "Add" a prescription from the front page
of the chart.
Under the "Action" header, you can edit the prescription (the green S shaped symbol). You can delete the prescription (the red x symbol). You can view some of the details of the prescription (the magnifying glass symbol) but some of the details do not display well. You can print or fax the prescription by clicking on the printer symbol. This is the best way to view previously written prescriptions.
You can lock the prescription (lock symbol).
Finally, you can annotate the prescription (folder symbol). The prescription will automatically be annotated
when it faxed. The annotation will show when the prescription was sent and to which phone number it was faxed.
- Current Problems: If you would like to instantly know the current
problems for which you are seeing the patient, you can add the current problems
to this module.
- Chronic Problems: This module allows entry and display of all chronic
problems that the patient has.
- Scanned Documents: All scanned or faxed documents associated with a
particular patient are in this folder. Other modules point to the files in this
folder.
- Lab Reports: Scanned and faxed files first are sent to Unfiled Faxes.
If the staff files a laboratory report in this patient's chart, it can be seen
in this module. Remember that the files are actually in the Scanned Documents
module and that the files displayed in the Lab Reports module point to files in the Scanned Documents module.
- Radiology Reports and Pathology Reports: The same principles apply to
these modules as the Lab Reports module.
- Previous Operations: This allows you to enter and display any
operations and the date of the operations that the patient has had.
- Patient messages: This module displays all office communications
regarding the patient. It is important to preserve all of these communications
for legal reasons.
- Historical Records: If you are converting from a paper chart system
to FreeMED, you can scan the paper chart to this folder. The organization of
your paper chart will be maintained. It is suggested that you not use the "Add"
button to add scanned images from your computer but instead scan directly
into FreeMED and then file your chart here.
- Forms: In this module, you can fill out a previously scanned form and
then print it or fax it. For instance, if you have to fill out a booking form
at the hospital for every patient for whom you want to perform an operation,
then you can will want to utilize this module. Scan in the hopital booking form,
then use FreeMED to complete the form. Then use FreeMED to fax the completed
form to the hospital. You may also fill out forms that you
use repeatedly in your practice.
You must put the scanned form in the
/usr/share/freemed/data/form/pdf directory. Make sure you scan in the form
according to the directions found at
http://developer.freemedsoftware.org/wiki/index.php/PDF_Form_Templating.
Then create the xml file for your form in the
/usr/share/freemed/data/form/templates directory. You will have one or two
templates in this directory which will show you how to create your desired
file. Also be sure to enter a new UUID for every entry in the XML file. If you
do not generate a new UUID for every entry, you will not be able to alter a
form once you have filled it out.
Once the form has been scanned in and the corresponding xml file has been
created, click on Add to select the form that you would like to fill out.
- Hospital Records: You can put scanned or faxed hospital records here.
For instance you might like to store the dischage summaries and discharge
labarotory results here. It is better to scan or fax the reports directly to
FreeMED and then file the reports here with the Unfiled faxes mechanism as
explained above.
- Notifications: If you would like to be reminded or if you would like
to remind your staff to schedule this patient or to order a laboratory test in the
future, then the reminder can be entered here. If you click on "Add" you will
be taken to another screen where the appropriate information can be entered.
- Treatments, Encounter notes, Lab values, Shots: These are modules
which were kindly contributed by Ronald Leemhuis, M.D. If you have questions
about these modules, please contact him directly at rpl121@verizon.net