This demo gives an overview of how a new admission will be documented in our EPR, and how a medical consult will be recorded.
Watch: the admission clerking and outpatient consult demo
Our new EPR will provide clinicians with structured documentation for inpatient admission clerking and outpatient consultations. These documents will be accessed from the clinical status board and completed within the patient’s record.
The medical admission clerking includes areas such as presenting complaint, review of systems, medications and allergies, mental health and safeguarding, frailty and delirium screening, examination, VTE assessment, diagnosis and management planning. Some information can be brought through from elsewhere in the EPR, helping avoid duplication.
The documentation is designed to be flexible. Clinicians can complete the sections relevant to the patient, with unused sections left out of the final clinical record. The system also records who completed and electronically signed the documentation, and when.
The outpatient consultation follows a similar structure, with additional information captured about the outcome of the clinic appointment and follow-up.
Key points
- Structured documentation: Admission and outpatient documents have consistent sections for recording patient information.
- Admission clerking: Covers history, medications, allergies, screening, examination, VTE assessment, diagnosis and management planning.
- Information brought forward: Some existing patient information, such as medications and previous documentation, can be brought into the new document.
- Only what is relevant: Unused sections are left blank and do not appear in the final clinical record.
- Electronic signing: Completed documents are signed using your PIN, recording who completed them and when.
- Outpatient consultation: Uses many of the same sections as inpatient documentation.
- One place to look: Clinicians can see information from previous admissions and other parts of the patient’s care without moving between different systems.
- Still being built: Some elements shown in the demo may change before go-live.