The patient record

Access to patient records

The patient record can be accessed by clicking on the patient's name in bold (always preceded by the administrative centre icon) from the following locations:

• Via search;
• Recently consulted section of the left-hand menu if it is one of the last eight files you consulted;
• Results module ;
• Tasks module;
• Pending notes module;
• Appointments module;
• Waiting room module
• Transmissions module

Patient record elements

The patient record is divided into three main sections:

Record header

Here you'll find the icon for the administrative centre (the purple person), the patient's administrative information (language, telephone and e-mail details, RAMQ registration with the family doctor - or group of doctors - and pharmacy details), information about consent in the file, and print buttons. This is also where the patient's file number can be entered. To access the Administrative Centre, simply click on the patient icon to the left of the patient's name.

When the screen size is reduced, an icon replaces the button text to optimise space. Detailed information is displayed in a contextual bubble by clicking on the corresponding icon. For example, vulnerability codes can be found under the stethoscope icon.

Record Summary

The right-hand section of the file is divided into various boxes that allow you to group certain information from the patient file by theme (results, medication, requests, vital signs, lifestyle habits and social context, allergies, clinical tools, programmes, immunisation and vaccines, problems,, history and family history) and highlight certain information.

Knowing that all professionals work differently and in order to optimize your daily practice, it is possible to rearrange the order of the summary boxes in the patient record. By doing this, you can choose to put the clinical tools on top, the vital signs lower and so on to accelerate your processes. An icon on top of the summary allows you to do modifications.

Clinical note

When a healthcare professional sees a patient, he or she begins to write a clinical note in which he or she adds all his or her checks and tests. The patient record therefore makes it possible to find everything that has been done or completed for the patient concerned when consent is valid. The QHR can also be accessed from the patient record, and a list of patient documents can be printed from it.

• Add a clinical note
  To start a new clinical note in the patient record, you have to click on consultation reason. Once the note is started, you can choose the note type, add documents, write content, add clinical tools and add vital sign results or any modification in the patient's profile.
  
  
• Write a clinical note (entry methods)
  Once you started the clinical note, you can use your keyboard to type the note content, but you can also use other entry methods such as voice recognition or macro functions with software like Dilato, Text Expander, or others.
  
  

  Save the note regularly by clicking on the Save button. Saving the note in the patient's file allows you to find it as a current note which can be retrieved and completed at a later date.

  When you complete the note, you indicate that the note is final. The Complete button replaces the act of signing the note on paper.

  When the screen size is reduced, an icon replaces the button text to optimise space.

• Modify/delete a clinical note
  By clicking on a clinical note's title in the patient record, it opens it and you can then modify it. To delete the clinical note, you need to follow the steps to modify it, delete the consultation reason, the tags, and its content, and then save it. If you do not find the clinical note you are looking for, it may hide behind the eye icon that filters the notes. The notes that appear straight away in the patient record are the ones with a consultation reason, tags, consultation details, or a conclusion. The others hide behind the eye, so you have to click on it to deactivate the filter.
  
  
• Understanding the clininal tools
  To accelerate the typing of a clinical note and to integrate practice standards, we developed a section in the clinical note to offer what we call clinical tools. The clinical tools regroup standard follow-up and evaluation forms (CNESST, insurances, APSS, obstetrical files, etc.), calculation tools (Framingham score, Cockcroft-Gault, etc.), anatomical charts, and note templates.
  Clinical tools have also been developed for some administrative regions and can be found in the Requisitions - XX category (where XX stands for the administrative region).
  As soon as a clinical tool is opened, it is included in the clinical note you were already in. You can retrieve it in the clinical note or in the Clinical tools module in the patient's record summary.

Patients search

The patient's search in Omnimed allows you to find patient records in the application. The search box is situated on top of the EMR at all times and from everywhere. To search effectively, you can use the record number, the HIN, the first name and last name, the date of birth, or the phone number as well as a combination of them.

Pending Notes module

The Notes review module allows you to see all notes in redaction from the healthcare professionals in your institution. While typing the note, you can save it to complete it later, complete it right away or send it in through a task to a professional in your institution. The saved notes appear in the Notes review module in the left menu. Then, at the end of the day, you can easily consult all saved notes to complete them.