Initially, entering a clinical note consists, on top of the information entered in the patient summary, of completing three separate fields: the consultation reason, the consultation details, and the conclusion. To this, you can add a confidential field that is composed of free text.
Add a confidential field to a note
The confidential field is not initially visible; it only appears by clicking on the padlock icon found at the bottom of the note.
When the user clicks on the padlock to include confidential information, a warning message appears and must be accepted in order to continue.
ℹ️ The content of the confidential field is not displayed when the clinical note is printed.
The usefulness of the confidential field
Omnimed offers a shareable electronic medical record (EMR). Thanks to this technology, physicians can access all of the information related to a patient directly within their EMR.
In order to make well-informed decisions on a patient’s health and his medical history, it’s important for the information to be accessible and that no information that can have an impact on clinical decisions be hidden. However, we are aware that certain medical information must remain confidential and not be available to all those who access a patient's file.
This feature would technically replace the action of striking out information on a paper document when the physician needs to hand off a copy of the record to a colleague.
Examples of information to be entered in the confidential field
A patient could entrust information such as:
- He suffers from domestic violence
- He is fearful of his mental health
- All other more informal information that is an integral part of the doctor-patient relationship
Whether at the request of a patient or by professional judgment, the doctor can decide that information must remain between him and his patient in order to maintain the bond of trust which unites them or the confidential nature of the subject.
Since the rest of his clinical notes will be accessible by all the other parties holding his mandate or the patient's consent, the sharing of clinical information, in order to facilitate the care of this patient, will be respected.
⚠️ Think about it!
It is important to properly understand that this field must not be used to write information that could have an impact on any future diagnosis or potential influence on the choice of treatment offered to a patient. Mistakes could be made based on the fact that important clinical information has been noted in a field invisible to anyone else but you, which could have medico-legal ramifications.