Recording clinical data in e-clinic

Mark LainchburyUncategorized0 Comments

There are many ways to securely and accurately record clinical data in e-clinic, and the method you choose is largely a matter of personal preference. We look at all the options below, including Word templates, PDF forms and hard-coded clinical questionnaires.

1) Appointment notes

Some practitioners simply choose to make free format notes which are linked to the appointment record. e-clinic also lets you to set up your own appointment notes templates, allowing you to order your notes into sections and complete text for each section. An outcome can be recorded for every appointment. Appointment notes are logged with the date, time and practitioner and can be securely locked. You can also makes notes on phone calls and other events.

Appointment Notes

Screenshot shows appointment notes using a template

2) Attaching files and photographs

A practitioner may also typically attach files or photographs to the patient record during the appointment. These may be facial photographs, x-rays, scanned documents or blood tests. You can also attach video or audio files.

X-ray

Screenshot shows an x-ray which has been attached to the patient record

Attached photo

Screenshot shows a photo attached to the patient record

3) Annotating images

e-clinic allows you to annotate an image or chart to show things like areas of pain or injection sites. We have some standard images but most practitioners prefer to load their own, which may reflect the paper charts and forms they were previously using.

Annotating face

Screenshot shows a diagram of a face annotated with injection sites and notes

4) Word templates

Many people prefer to record clinical notes into Word. You can create your own template for any treatment and then copy and paste ‘bookmarks’ into the template. These pull through information from the patient’s file like name, age, date of appointment, date of birth and so on, as soon as the template is opened. You can also add items like checkboxes. Once the template is opened and the patient information pulled through, you can then add your own notes during or after the consultation or treatment. You would then simply save the Word document with there patient record.

Word Clinical Form

Screenshot shows a Word template pulling through patient data and allowing input to fields

5) PDF forms stored as data

A sophisticated way to record clinical data in e-clinic is with a custom PDF form. If you already have skills in creating PDF forms using Adobe Acrobat, you may want to create your own, but we normally find that clients prefer us to do this as bespoke development. A paper form can be transformed into a PDF with drop-downs, checkboxes and free text areas. The form is called up and completed during consultation or treatment, then stored against the patient record. The most impressive aspect is that, unlike with Word template, input is stored as data fields, meaning it can be reported on or exported at a later date.

Clinical PDF

Screenshot shows a PDF form

6) Hard-coded clinical forms

Any medical or clinical form can be hardcoded into e-clinic by our development team. A form created in this way can include drop-downs, checkboxes and free text and fields are stored as data.

Hardcoded form

Screenshot shows a bespoke clinical form hardcoded into e-clinic

A basic consent form can be created in e-clinic and signed on an iPad by the patient. Consent forms created in this way would simply consist of text, which the patient reads and then signs. If you want a more complex consent form which encompasses checkboxes for example, it would be better to create it as a Word template or ask us to create a hard-coded form.

Consent form

Screenshot shows a consent form which can be signed on an iPad