Patient Information Windows

BACKGROUND INFORMATION

Social & Family History - Other Medications - Medical History - Ongoing Concerns - Reminders

Any information entered in the five boxes at the top of the e-Chart screen will carry forward to subsequent encounter records. All five areas are free typing boxes and the SAVE button at the bottom of the screen saves all information in this window. Just click in the area you want, type and SAVE.

ALLERGIES & PRESCRIPTIONS

With oscarRx you can write prescriptions quickly and easily and keep a record of past and present medications too. The program can also alert you to any allergies the patient has, and informs you if there is a known problem with mixing two different medications.

• The ALLERGIES link will take you to the patient’s oscarRx Allergy Profile. See Chapter 7
• The PRECRIPTIONS link will take you to the main oscarRx page. See Chapter 7

ENCOUNTER NOTES

• All of the notes in the patient’s Electronic Chart are kept as a cumulative report for easy reference.
• Today’s date will appear under the last note and the cursor will fall under the date, in order to begin your note on the encounter.
• If a reason for the encounter was entered in the REASON box when the appointment was booked, it will automatically be inserted beside the date in the encounter note.
• Use templates as a guide to writing up the encounter note for common examinations and disorders. For instructions on how to insert a template into the encounter notes, see Encounter Templates
  
• If you want to finish the note later, click on SAVE. When the note is completed click on Sign, Save & Exit to save the electronic record, sign your name and exit back to the appointment screen.

Archiving Clinical Notes

When the clinical notes of a file get too long, it slows down the response of the program. OSCAR allows you to split the file and archive in an easy-to-access location. When the file gets to 50%, a ‘SPLIT’ button will appear on the clinical note area and the colour of the % bar turns from green to orange.

When the ‘SPLIT’ button appears in the clinical note area and the % bar has turned from green to orange:

1. Click on the SPLIT button
2. Say YES to the question, “Are you sure you want to split the file?”
3. Click the ENCOUNTER link to view the archived clinical notes

ADJUSTING THE WINDOW VIEW SIZE

On the upper right corner of each patient information window within the e-Chart screen you will see the letters X | S | N | L | F | R to adjust your view of each window of information

• X closes a window if you do not want to use it
• S gives you a small window
• N gives you the normal or default view
• L gives you a large view
• F gives you a full view
• R resets the view to the default

BUTTONS

• SAVE: click when you have partially finished a note and have to leave it temporarily.
• SIGN/SAVE/EXIT: used for a residents to click when they have finished a clinical note. Background of 1st icon on appointment bar turns white.
• VERIFY & SIGN: used for a supervisor to click after reading a clinical note written by a resident.  As well, a doctor can use this button for their own clinical notes. Only users with doctor or locum roles can use this functions; nurses cannot.
  Background of 1st icon on appointment bar turns orange.