Medical Note

The note entry is intended for patient visits, where is the doctor has seen the patient.

Nursing Note

Where the patient has been seen by the nurse, and the nursing notes are to be recorded in the patients file.

Paramedical Note

Where the patient has been seen by a technician or similar and the notes are to be recorded in the patients file.
This will differentiate the entry from the Doctors note.

Comment

A comment entry is intended when something needs to be recorded onto the patient's file when the doctor has not seen the patient. It may be that a staff member wishes to record that the patient had phoned, or to record incoming mail.

Operation Note

This allows you to record your operation details. In the notes, what you type is preceded by the word OPERATION for ease of identification.
The Accounts Check List also looks for a fee or invoice in excess of $x (where x is set by you – see Setup - Provider - User Configuration)

Pathology Result

This allows you to type in any pathology results if they have not been received electronically. The heading PATHOLOGY will appear on the patient notes screen, easily identifiable from the rest of the patient notes.

Pathology report values can be shown in a graph format in Patient > Lab Results

*

External Document

External documents are those that are sent to you by a method other than the Messaging Carriers (such as Healthlink / Argus etc). For instance, an email might contain an attachments. These can be saved and attached to the patient file as an External Document.

Emails and their attachments can also be imported directly from the Message Centre

See Also: Linking External Documents from the Message Centre

Histology Result

This allows you to type in any histology results if they have not been received electronically. The heading HISTOLOGY will appear on the patient notes screen, easily identifiable from the rest of the patient notes.

*

Caution

A caution appears every time you select the patient.
(providing the operator has permissions to View the Medical Alerts - see OPERATORS).

Cautions can also be set in the Alerts area of Patient > Registration

CAUTIONS & MEDICAL WARNINGS

X-Ray Result

This allows you to type in any x-ray results if they have not been received electronically. The heading X-RAY will appear on the patient notes screen, easily identifiable from the rest of the patient notes.

*

Scanned Document

Scanning is normally done by scanning the document directly to the patient file (see SCAN A DOCUMENT. Where the document has already been scanned and saved outside of the Incisive application, it can then be attached by using this option.

See Also: Importing scanned documents from a folder

SCANNED DOCUMENT

Medical Warning

A Medical Warning is similar to a caution except that it is either always displayed or needs to be signed off by the operator every time it appears. For use in a hospital database only.

Medical Warnings can also be set in the Alerts area of Patient > Registration

CAUTIONS & MEDICAL WARNINGS

ARTP

This is the Incisive 'Assessment Report and Treatment Plan' (as approved by Accident Compensation Corporation).

CREATING AN ARTP

Medical Summary

A Medical Summary can be entered (and added to). The Medical Summary will always appear at the top of the patients notes.

Text can be added directly or uploaded while using the TYPE Dictation function in Dictation

MEDICAL SUMMARY

Nursing Care Plan

A Nursing Care Plan allows text to be entered.  The NCP will always appear at the top of the patient's notes; like the Medical Summary.  The NCP option will only appear if the Site is set to 'Private Hospital Manager' and the User/Provider is set to 'Is Hospital' in Setup > Provider > Config 1

Message - To Do

Worksheet

This is an old style of using custom-designed forms to fill and store standard data collection.

It has been superseded by the Field Forms function in Setup > Templates > Forms > Field Forms

WORKSHEET

IPM ARTP

Intervention Pain Management Assessment Report and Treatment Plan.

*

Pathology, Histology and X-Ray results are mostly received as secure messages and imported into the database. If they are not received via this method, they will more than likely be scanned, rather than retyped into the patient file.

These options are a carry over from the original Incisive application pre scanners and HL7 messaging. In time, these options will be removed, as we believe that they are now obsolete.