Clinical documentation
Writing clinical documents
The first choice in clinical documentation is to select a document template. The next step is to select a keyword from a list under which the text belongs (keywords are used for searching, statistics and follow-up).
The system provides powerful tools to enter text for structured measurements and diagnosis (including ICD10 codes). Various word processing tools are also available. Writing clinical documents in Profdoc is fast an efficient and can be done without using the mouse if so desired.
Chronological record
Here, all the clinical documentation for the patient is shown in reverse chronological order with the most recent document at the beginning. By highlighting one or several documents in the list, the user can choose what content to be displayed at the right side of the screen.
Version control of clinical documentation
When clinical documents are displayed, the latest version is always showed. With only a few mouse clicks it is possible to backspace in time and view the history of the document.
Who did what and when to the document is always stored alongside each version. Thereby, it is possible to trace all changes to the clinical documentation.
One case record file
Each patient registered in Profdoc has one case record file. Here, all practitioners such as doctors, nurses, physiotherapists, and dieticians do their clinical documentation. Each profession uses their own templates with structured and searchable keywords.
When information is displayed, it can be presented for an individual profession only or several together for a complete picture of all clinical documents.
One or several clinical documents can be chosen to be printed on paper. Printing happens either on the local printer or via the network. The selected printouts can be examined in a preview function on screen before being sent to the printer.
Filtering
A powerful filtering function is available to filter out and select clinical documents of special interest. If a practitioner is looking for a quick overview of a new patient, he or she may only want to look at all admission and discharge letters.
Another way to filter would be by keywords in each document, and for example bring forward all documents containing the word ‘pulse’. The user simply enters the parameters of interest, and Profdoc filters out those documents that do not meet the search criteria.
The following filtering functions are currently available in Profdoc HIS:
- Ward
- Document template
- Practitioner category
- Keyword
It is also possible to combine different search criteria, for example “show all documents written by a doctor which contain the keyword ‘conclusion’”. Profdoc then combines the search criteria and shows the corresponding documents.
