Doctor's workstation - what is it. A doctor's workstation - an additional burden or a doctor's assistant? Description of the form "Referral for laboratory research"

Program intended for maintaining medical records in an outpatient setting.

Year: 2011
Version: 4.2.02
Developer: Leybasoft
Platform: Windows XP SP2 and higher
Vista Compatibility: complete
System requirements:
- Processor: P-III (Celeron 1.5 GHz) or higher
- RAM: 512 MB (min 256 MB) or more (recommended)
- HDD space: 100 MB or more (depending on the growth rate of the database file size)
- administrator rights (only for installing software and configuring the server)
Interface language: only Russian
Tablet: Not required
The size: 172 MB

It was written to help fellow doctors who are obliged to do the impossible as soon as possible: to issue an outpatient card in accordance with all the rules, listen carefully to the patient, comprehend what was said and prescribe an adequate examination and treatment.

The program is technically a two-tier client-server ("thick" client). The Firebird RDBMS is used as a server, which allows multi-user access to data and use of the application in the local network. Access to data is strictly regulated depending on the group under which the user logs in to the database (in a word, everyone will "see" only the data that he is allowed to "look at").

Add. Information: Previous release of the program (version 4.1.08)

What's new in this version:

1. Along with the multi-user version (using a full-fledged server that requires separate installation and configuration), the so-called. portable version (single-user, containing a built-in server that does not require configuration). The portable version allows the doctor to keep the program + server + his database on an ordinary flash drive or USB HDD. It is very convenient if you want to work with the database at work and at home, moreover, if you have absolutely no desire to delve into the intricacies of database administration.

2. Added the ability to enter some data in Latin (at the request of colleagues from abroad)

3. The interface has been improved in some places (the connection window in the multi-user version now has three display modes) + numerous "goodies" and "conveniences" have been implemented, obvious bugs have been fixed

4. Added HTML help format in addition to the existing chm format

See the help page for details...

Since this version is only for work urologist-andrologist, the author invites colleagues gynecologists, dermatovenereologists, therapists, neuropathologists and so on to cooperate. to expand similar functionality in the program. Constructive comments on the content and usability of this version are also welcome.

How to contribute to the further development of the software
1. We look at the program interface
2. We catch the logic of work and the relationship between the marked interface elements and the generated data
3. We send complaints/symptoms united by the same logic and the corresponding "typical" description of complaints/symptoms found in domestic (or "near-foreign") medical documentation (of course, in the specialty that you want to see in program). You can also add here what other templates (statistical coupons and other waste products of medical bureaucrats) can be added.

Rice. 60. Form "Calling a doctor at home"

To save a new call, press the button https://pandia.ru/text/78/352/images/image094_2.gif" width="72" height="24">.

After saving, the newly created call will be added to the table of records "Calling a doctor at home".

3. AWP "Polyclinic doctor"

The automated workplace of a doctor in a polyclinic of a medical institution allows you to keep a personalized record of visits and services rendered. Provides quick access to medical records of patients entered in the document management system, and makes it possible to issue a prescription, referral, and work with updated medical directories.

Main functions AWP "Polyclinic Doctor":

· Viewing lists of patients who made an appointment, making an appointment and obtaining information about the patient from the registration database;

· Access to outpatient medical records and outpatient visit vouchers;

· Issuance of prescriptions (DLO, on forms of strict accountability and regular ones);

Formation of directions;

· Issuance of directions, printing of directions (form No. 000/у-04 according to Order 255);

· Access to medical reference books (MBK-10, Medicines, INN, etc.);

· Access to dispensary observation cards.

https://pandia.ru/text/78/352/images/image131_2.gif" width="304 height=287" height="287">

Rice. 62. Doctor's Choice Form

A quick search for a doctor in the database is carried out when filling in the field "The Doctor's Code", it is also possible to search by field "Surname". Clicking the button with the mouse will bring up the record table window "Doctors" to select a doctor from the records table (Fig. 63):

Rice. 63. Table of records "Doctors"

To select a specific doctor, it is enough to double-click on the required entry, or, after highlighting the desired doctor, press ctrl+ Enter. More detailed work with the record table window (turning on/off the filter, search, and so on) is discussed in paragraphs 1.4–1.10.

The choice of a doctor is saved in this session with the program, allowing the program to select data from the database for the selected doctor.

More detailed work with windows of record tables (turning on/off the filter, searching, creating a new record, and so on) is discussed in the sections of this Guide.

3.2. "Schedule View" operation

Operation "Schedule View" designed to view and adjust the doctor's watch grid. To view the schedule, click on the name of the operation "Schedule View" in the area of ​​operations (Fig. 64).

Rice. 64. Selecting the operation "Scheduling"

A window appears in the working area of ​​the Program "Schedule View".

In this window, the Program provides you with the ability to view and edit the current doctor's schedule (Fig. 65).

Rice. Fig. 65. General view of the "Schedule View" window

This form provides a standard set of scheduling actions.

In addition, this window allows you to change the current status of the entry. Double-click the right mouse button on an entry with the status of "Initial admission" (lilac highlight), "Re-admission" (pink highlight) or "Initial intake" (red color), a context menu will appear (Fig. 66):

Rice. 66. Context menu of the entry with the status "Initial reception"

Selecting an item "Summon Patient", you will change the status of the entry to “Patient Called” (dark green), which will be reflected in the schedule grid (Fig. 67).

Rice. 67. Record status "Patient called"

By accessing the context menu again (Fig. 66) and selecting the start item “Start reception” (Fig. 68), you can switch the record to the “Patient at the reception” (white) state (Fig. 69).

Rice. Fig. 68. Context menu of the entry with the status "Patient called"

Rice. 69. Record status "Patient on admission"

Finally, by calling the context menu of the "white" record, we can end the reception by selecting the "End reception" item (Fig. 70).

Rice. Fig. 70. Context menu of the entry with the status "Patient at the reception"

In this case, the record will take on the status “Patient reception completed” and will be highlighted in blue (Fig. 71).

Rice. 71. The status of the record "Patient's appointment is over"

Using the recording context menu (Fig. 66), namely the “Book an appointment” context menu item, you can record the patient for the next appointment, the “MKAB” and “TAP” context menu items, respectively, allow you to view the patient’s MKAB and TAP.

3.3. Operation "Doctor's Appointments"

Operation "Doctor Appointments" is designed to record and view registered patients for a specific date and time. To view those who have signed up for an appointment, click on the name of the operation "Doctor Appointments" in the area of ​​operations (Fig. 72).

Rice. 72. Selecting the operation "Register for a doctor's appointment"

A form appears in the working area of ​​the Program "Quick Recording" (Fig. 73):

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Rice. 74. Selecting the operation "Issue directions"

a table of records appears in the working area of ​​the Program "Direction"(Fig. 75).

Rice. 75. Table of records "Direction"

In this table you can find the necessary direction, view it or edit it..gif" width="23" height="22 src="> ( "Add New Entry").

A form will appear on the screen. "Direction"(Fig. 76):

https://pandia.ru/text/78/352/images/image146_1.gif" width="532" height="394">

Rice. Fig. 77. Window "Report" print preview of the direction

More detailed work with windows of record tables (turning on/off the filter, searching, creating a new record, and so on) is discussed in the sections of this Guide.

3.5. Direction for research

To form research directions, you need to use the operation "Study". When you select this operation by clicking on the name of the operation "Study" in the operations area (Fig. 78):

https://pandia.ru/text/78/352/images/image148.jpg" width="374 height=151" height="151">

Rice. 79. Table of records "Research"

In this table you can find the necessary direction for the study, view it or edit it. To view the direction for research, select the required direction in the table and click the icon ) on the icon bar of the records table window. To create a new research direction, select the icon ( "Add New Entry").

A form will appear on the screen. "Research Direction"(Fig. 84):

https://pandia.ru/text/78/352/images/image151_0.jpg" width="608" height="448">

Rice. Fig. 81. Window "Report" of the print preview of the direction for the study

More detailed work with windows of record tables (turning on/off the filter, searching, creating a new record, and so on) is discussed in the sections of this Guide.

3.6. Working with medical records

To start working with patients' medical records, select an operation "Medical card"(Fig. 82) .

Rice. 82. Selecting the operation "Medical record"

As a result, the table of records "MKAB" will open (Fig. 83).

Rice. 83. Table of records "Medical record of an outpatient"

You can read more about working with medical records in Section 2.1. – 2.2, work with windows of tables of records (turning on/off the filter, searching, creating a new record, and so on) is considered in the sections of this Guide.

3.7. Working with outpatient coupons

To start working with outpatient coupons, select an operation "Outpatient Card" (Fig. 84).

Rice. 84. Choice of operation "Coupon of the outpatient patient"

A window will appear with a list of TAPs related to the current (selected) doctor (Fig. 85).

Rice. 85. Table of records "Coupon of an outpatient patient"

To display the full list of coupons, click the button on the records control panel (for more information about how filters work, see section 1.10)

Working with outpatient visit vouchers is described in detail in section 2.3, work with record tables windows (turning on/off the filter, searching, creating a new record, and so on) is discussed in the sections of this Guide.

3.8. Operation "Call a doctor at home"

To issue a doctor's house call, select the operation "Call a doctor at home" (Fig. 86).

Rice. 86. Selecting the operation "House calls"

The Physician House Call records table appears, containing records of house calls made by the current physician.

Rice. 87. Table of records "Calling a doctor at home"

Working with calls is described in detail in section 2.5, work with windows of record tables (turning on/off the filter, searching, creating a new record, and so on) is considered in the sections of this Guide.

3.9. Operation "Dispensary observation"

To generate dispensary records, as well as to see the records of dispensary visits, you need to use the operation "Dispensary observation"(Fig. 88).

https://pandia.ru/text/78/352/images/image160_0.jpg" width="325 height=274" height="274">

Rice. 89. Table of records "Direction"

In this table you can find the necessary dispensary record card, view it or edit it. To view the dispensary record card, select the required dispensary record card in the table and click the icon ("Edit current entry") on the icon bar of the records table window. To create a new dispensary record card, select the icon ( "Add New Entry"), after you click on the “Add new record” button, the “Adding dispensary patient” window will appear on the screen (Fig. 90):

Rice. Fig. 90. Window "Adding dispensary patient"

The "Adding a dispensary patient" window has two tabs (Fig. 90) "Dispensary registration card" and "Dispensary visits". The fields of the "Dispensary record card" tab (Fig. 90) are filled with general information about the patient, the "Dispensary visits" tab stores information about the patient's dispensary visits (Fig. 91).

Rice. 91. Bookmark "Dispensary visits"

After filling in the form fields, you need to click the button to save the dispensary registration card. at the bottom of the form.

More detailed work with windows of record tables (turning on/off the filter, searching, creating a new record, and so on) is discussed in the sections of this Guide.

4. AWS "OrgMethodCabinet"

Automated workplace "OrgMethodCabinet" is designed to automate the organizational activities of the head of the department of the clinic.

The main functions of the workstation "OrgMethodCabinet":

· Scheduling the work of doctors;

Maintaining and registering medical personnel;

· Management of doctors' sites;

Maintaining offices and departments of the clinic.

Rice. 92. General view of the AWS "OrgMethodKabinet"

As you can see in the figure of the operation panel, located in the left part of the program window, the following operations are available: "Scheduling doctors", "Plot", "Medical staff", "Department", "Cabinet".

4.1. Scheduling doctors

In order to start working with the schedule of doctors, you need to click in the area of ​​operations to select the operation "Scheduling doctors" (Fig. 93).

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Rice. 95. Criteria for the selection of doctors

There are four criteria available:

departments;

· Cabinets;

· Plots;

· Without a filter

By selecting one of the criteria in the table below, a list of departments, offices, sections will be displayed. (Fig. 96).

Rice. 96. List of branches

By selecting a department, office or area, the doctors assigned to it will be displayed on the right in the list of doctors (2) (Fig. 94). The list of doctors allows you to choose to view the schedule of one or more doctors. To do this, you need to check or uncheck the box next to the corresponding surname (Fig. 97).

Rice. 97. Viewing the schedule of two doctors at the same time

The schedule area is intended for viewing and creating a schedule of doctor's appointments.

To create a grid, first select a date in the calendar (3) (Fig..gif" width="139 height=40" height="40"> on the doctor's panel and select "Generator" in the list that opens (then the schedule will only be created for this doctor) (Fig. 98).

Rice. 98. Drop-down menu of the "Create Schedule" button

This will open the New Schedule window (Fig. 99).

https://pandia.ru/text/78/352/images/image177_0.gif" width="76" height="23 src=">. In the schedule grid (4) (Fig. 94), the created schedule is displayed in green (Fig. 100).

Rice. 100. New Schedule window

You can also create an individual breakdown for the doctor. Click the button in the "Schedule Creation Wizard" window, an additional area will open (Fig. 101). In it, you need to set the intervals for visiting a doctor.

Rice. Figure 101. Schedule Wizard window with additional area open

For example, you need to create the following schedule for a doctor: working hours from 9 am to 6 pm, one appointment lasts 20 minutes, a break from 1 pm to 2 pm, and recording rights from 9 am to 6 pm will be to have a doctor, and from 14 to 18 - a registry, as well as patients using an infomat for recording. To do this, we need to create two intervals. In the interval start field, enter 09:00, the end of the interval is 13:00, the time of one appointment is 20, and give access rights to the doctor by checking the box in the Doctor field and click https://pandia.ru/text/78/352/images /image181.gif" width="65" height="23">. Two rows will be displayed in the Added Schedule Intervals table (Fig. 102).

Rice. 102. Table "Added intervals of the schedule"

Click the button https://pandia.ru/text/78/352/images/image183_0.jpg" width="330" height="412">

Rice. 103. New Schedule window

The program allows you to copy the schedule from one date to another date..jpg" width="272" height="127">

Rice. 104. Drop-down menus of the "Copy schedule" button

The Copy Schedule window will open (Fig. 105).

https://pandia.ru/text/78/352/images/image187_0.gif" width="196" height="36"> or for a period of time . In the list below, select the doctors for whom the schedule will be copied. If copying from date to date takes place, then it is enough to select the date from which the schedule is copied from the "Date - source" calendar, and the date for which the schedule is copied from the "Date - destination" calendar.

If a period of time is being copied, then in the "Period - source" calendar, it is necessary to select the period of time. To do this, select the start date of the period and, holding down the "Shift" key, select the end date of the period. In the "Date - receiver" calendar, only the date is indicated - the beginning of the period for which copying is carried out.

After the dates or periods of copying are set, it is necessary to press the button

The program also allows you to copy the schedule between doctors. To do this, click the arrow on the button. and in the list that appears (Fig. 104) select "Copy from doctor to doctor".

The window "Copying a schedule from one doctor to another" will open (Fig. 106).

https://pandia.ru/text/78/352/images/image192_0.gif" width="35 height=36" height="36"> to the left of it. The doctor will move to the "Whose to copy" field. Now in the list “Selected doctors”, mark one or several doctors for whom copying will be carried out, and click the button to the right of the list, after which the selected doctors will move to the “Copy for” field (Fig. 107).

Rice. 107. Choosing a Doctor

Now select the date or period you want to copy and the date to which it is copied and click the button.

To assign a vacation or day off for a doctor, click the arrow located on the button (Fig. 98).

https://pandia.ru/text/78/352/images/image197.jpg" width="371" height="247">

Rice. 109. Display non-reception days

The program allows you to delete the schedule for the date, as well as for the period for the specified doctor. To delete for a period, click the arrow on the button and in the list that appears, select "Delete schedule for the period" (Fig. 110).

Rice. 110. Drop-down menu of the "Delete schedules" button

In the window that opens, specify the period for which you want to delete the schedule (Fig. 111).

Rice. 111. Window "Delete doctor's schedule"

If you need to delete a schedule for a date, click the button , without opening the drop-down menu, after selecting the date in the calendar (3) (Fig. 94). After that, a window will appear asking you to confirm the deletion of the schedule for the specified date.

Rice. 112. Window with a request to confirm the deletion of the schedule for the date

4.2. Work with polyclinic sites

The program allows you to process a table of polyclinic sites - create a new site, assign territory, doctors, and so on. When choosing an operation "Plot" (Error! Reference source not found.)

a table of parcel records appears in the working area of ​​the Program (Fig. 113).

https://pandia.ru/text/78/352/images/image098_2.gif" width="23" height="22">. A window will appear "Doctor's Office"(Fig. 114).

https://pandia.ru/text/78/352/images/image205_0.jpg" width="224" height="249 src=">

Rice. 115. Selecting the operation "Doctors"

When you select an operation in the workspace of the Program, a table of records appears "Medical staff"(Fig. 116).

https://pandia.ru/text/78/352/images/image098_2.gif" width="23" height="22">. A form for adding a new employee of a medical institution will appear (Fig. 117).

Rice. 117. Form for adding an employee of a healthcare facility

If this employee is a doctor, check the box "This employee is a doctor". In order for an employee to become available on the schedule, you must check the box "Available on the schedule".

This document is a user guide for the software of the regional segment of the unified state information system in the field of health care (hereinafter referred to as RMIS), designed to automate the work of medical personnel of health facilities. The user manual is intended for the automated work of a general practitioner.

Application area

The "Events" module is used to automate the activities of medical organizations providing preventive care on an outpatient basis. The module is designed to manage patient flows and personalized accounting of medical care provided.

Brief Description of Features

AWP of a general practitioner is designed to perform the following functions:

• provision of services to the patient;

User experience level

To work in the system, the user must have basic skills in working with a personal computer and an Internet browser (Internet browser).

Purpose and conditions of use

Automated Functions

The module is designed to automate the medical examination of the adult population. Allows you to provide services to patients, form a conclusion

Software and hardware system requirements

The workplace must meet the requirements presented in Table 1.
Table 1 - Software and hardware requirements for the system

Preparation for work

System start

• launch an Internet browser;
• enter the application URL in the address bar of the browser. Wait for the authorization page to load.

After establishing a connection with the system, the user authorization page opens in accordance with Figure 1.

Figure 1 - User authorization page
To log in, follow these steps:

• in the "Username" field, enter the username (login);
• enter the password in the "Password" field;
• click the "Login" button.

If you are not registered in the system, please contact your administrator. After registration, your login and password will be sent to your email address.
In case of successful authorization, the main system window opens in accordance with Figure 2. Otherwise, an authorization error message is displayed in accordance with Figure 3.
In case of an authorization error, you should repeat the authorization data entry, taking into account the case and keyboard layout.

Figure 2 - Main window of the system


Figure 3 - Authorization error message

System health check

The software is operational if, as a result of the user's actions described in section 3, the page of the main system window is loaded without giving the user error messages.

Description of operations

Name of operations

In the module "Medical examination of the adult population", the doctor's functions are:

• provision of services to the patient;
• viewing a list of patient services;
• formation of the final results of medical examination.

Operation conditions

To successfully complete the operations, you need to launch the application and log in in accordance with section 3 of this manual.

Basic actions

To get started, you need to log in to RMIS. In the module navigation menu, select "Medical examination of the adult population":


Figure 4 - Module "Medical examination of the adult population"
After logging in, the main page of the module will open, where the list of events available in the system is displayed in the left part of the window in accordance with Figure 5, and in the right part, the list of patients of the selected event in accordance with Section 4.3.2.


Figure 5 - Working panel of the GP

Section "Patients"

The "Patients" section is represented by a filter for searching patients and a list of medical examination cards for the selected event.
The list displays the patient's code, the patient's full name, year of birth, start and end dates of the medical examination case, the percentage of services rendered to the patient out of those assigned when selecting or adding a patient.
The function buttons block contains the following buttons:

• "More" button according to Figure 6:

Figure 6 - Me button "More"

• "Add patient" button - when you click on the button, a modal window will open for searching by the entered full name from the database in accordance with Figure 7:

Figure 7 - Form for adding a patient
After selection, the patient is added to the event list and a patient examination card is created. You cannot add a patient repeatedly to the same event, the system displays a corresponding message.

• button "Change appointments" - when you click on the button, a window will open with the ability to change the assigned services to the patient:

Figure 8 - Form for changing assignments
By default, services are assigned according to patient models, but before obtaining consent to undergo a medical examination, their list can be changed. This applies, for example, when a patient with benefits is added to an event and the list of services must be assigned based on the nearest age specified in a regulatory order, etc. After obtaining consent, changing the list of services will not be available;

• “EMC” button - transition to the case of patient care in the “EMC” module in RMIS. The button is available if a case has been generated for the patient (after the first service has been rendered):

Figure 9 - Service case in EMC

• "Scheduling" button - when you click on the button, a list opens for selecting manual or automatic planning. With automatic planning, the selected patients are evenly distributed within the period of the event.

Important! For medical examination of the adult population, selected patients are distributed evenly over 12 months .
For manual planning, you must enter the planned date for the selected patient;

• the "Consent" button - calls a modal window in which the date of the patient's consent to undergo a medical examination is fixed in accordance with Figure 14. After saving the consent, the patient is assigned services and it is no longer possible to change their list (on the "Change appointments" form);

Figure 10 - Form "Consent"

• the "Cancel" button - calls a modal window in which a complete or partial refusal of services is recorded:

Figure 11 - Form "Refusal"
Important! Removing the checkbox from the "Refuse partially" field does not remove the choice from the list of services (checkbox);

• button "Questionnaire" - calls the form for the provision of a questionnaire service in accordance with Figure 12:

Figure 12 - Form "Questionnaire"
Not available until consent is obtained;

• button "Anthropometry" - calls the form for the provision of anthropometry services in accordance with Figure 13:

Figure 13 - Service form "Anthropometry"
Unavailable until consent is obtained and the survey service is provided;

• button "Go to CP" - transition to the "Patients" module in the patient's card;
• "Card" button - the button opens the patient's medical examination card. Available if the consent of the patient is obtained and the services of questioning and anthropometry are provided. Description of the form in section 4.3.2;
• "Reports" button - when you click on the button, a list of reports opens:

Figure 14 - Menu button "Reports"

Medical examination card

The form "Medical examination card" in accordance with Figure 15 can be divided into several parts:


Figure 15 - Form "Medical examination card"

• block "Patient card" - contains basic data on the patient. Non-editable information, inherited from the "Patient Card" in RMIS;
• "Diagnoses" tab - a tab for entering the patient's diagnoses established during the medical examination;
• block "Results of services" - contains a list of services assigned to the patient as part of the medical examination. See Section 4.3.2.1 for a detailed description of the block;
• block "Code of diagnoses" - in the code of diagnoses displays the diagnoses set on the tab "Reception of the therapist";
• tab "Reception of the therapist" - a tab for fixing the results of the event;
• tab "Risk Factors" - tabs for fixing the parameters of the patient's health status;
• tab "Conclusion" - the main final data on the patient's medical examination are recorded;
• tab "Reports" -
• tab "Directions" -

Diagnosis Tab

The form is presented in the form of a table for creating, deleting and editing patient diagnoses in accordance with Figure 16:

Figure 16 - Tab "Diagnosis"
When filling in the parameters of the diagnosis, you should indicate the service on which the diagnosis was made, the diagnosis code according to ICD-10, indicate the nature of the disease and the type of diagnosis:


Figure 17 - Form for adding a diagnosis
After saving the form, the diagnosis will appear in the list on the "Diagnoses" tab, as well as in the "Summary of diagnoses" block.

Service Results Form

The “Results of services” form includes a table with a list of services grouped by status: “Rejected”, “Rendered”, “Assigned” (if the case is not closed), “Rendered earlier”:

Figure 18 - Form "Results of services"
The following functional buttons are available for all services:


Figure 19 - The result of the services rendered

• “Expand” button - opens services and their values;
• “Minimize” button - minimizes all services;
• "Search" button - when you click on the service, a prompt appears in accordance with Figure 20. "Search" button when you press the "Enter" button on the keyboard.

Figure 20 - Tooltips for function buttons
The service search window opens. If the service is not found, it can be created by setting the flag "Create such a service":


Figure 21 - Service search
Service search (creation) form fields:

Figure 22 - Service editing form

Figure 23 - Deleting a service
If during the provision of a service a parameter is entered that goes beyond the limits of the norm for this service, then the service or the corresponding parameter is tinted in red:


Figure 24 - Highlighting a parameter that has gone beyond the limits of the norm

Block "Code of diagnoses"

In the list of diagnoses displays both the diagnoses set on the "Therapist's Appointment" tab, and the diagnoses, entered on the "Diagnosis" tab.
When a diagnosis is made through the "Diagnoses" tab or at a therapist's appointment, the diagnosis falls into the summary depending on the specified nature of the disease, the date of its establishment is also displayed. If several diagnoses are entered that are included in the same summary interval and their dates differ, then the first date is set.


Figure 25 - Summary of diagnoses
Important! The set of diagnoses is associated with the parameters of the services provided. When service parameters exceed the normative limits (configurable in Settings > Service Parameters), the corresponding summary line is highlighted in red. When hovering over a line, a message is displayed containing the name of the service and the normative limits of the parameter that has gone beyond the norm:


Figure 26 - Diagnosis highlighting and justification output
The diagnoses in the summary can be edited using the Edit button:


Figure 27 Diagnosis editing form

Therapist Appointment Tab

Figure 28 - Entering the therapist examination service
On the tab, you must fill in the required fields:

• field "Resource" - a directory of resources for the organization of the event. Limited by resources providing the selected service;
• field "Date of rendering" - a calendar for entering the date of rendering the service;
• field "Main diagnosis";
• field "Character of the disease".

After the inspection, in the group of fields below, the flags indicate the necessary data. After filling in the fields, the form must be saved.
The data entered on the form can be edited in the block "Results of services" > "Rendered" > "Reception (examination) of a general practitioner", press the "Insert" button on the keyboard:


Figure 29 - Editing the "Therapist's Appointment" service
This will open a form as shown in Figure 22.

Risk factors tab

The patient's risk factors are recorded on the form, some of which are filled in automatically based on the results of the services provided, including questionnaires:

Figure 30 - Tab "Risk Factors"
Fill in the required fields and specify the values ​​from the drop-down list. Click on the "Save" button. If necessary, you can make changes using the "Edit" button.

Conclusion tab

The form contains the main final data on the patient's medical examination:


Figure 31 - Making a conclusion
Here you can assign a health group to the patient and, if necessary, indicate directions, or D-registration. The form is presented as a set of fields to fill in:

• field "Date of opening" - a non-editable field, generated automatically by the date of the provision of the survey service;
• “Closing date” field is a non-editable field, set automatically according to the date of the therapist's service. To save, you need to open the form in edit mode and confirm the set value;
• the field "Health group" - is indicated according to the results of the medical examination.

Reports tab

By clicking on the "Reports" tab, you can generate reports on the event. There are two buttons on the tab: "Therapist's examination" and "Results of the provision of services", when you click on the button, a corresponding report is generated.


Figure 32 - Report generation form
The report "Examination of a general practitioner" includes the definition of a group of health status, a dispensary observation group, a brief preventive consultation:


Figure 33 - Report "Examination of a general practitioner"
The report "Results of rendered services" displays only the rendered services of the patient:


Figure 34 - Report "Results of rendered services"
Reports generated in this way can be printed and signed.

Printing a medical examination report

After the doctor has entered all the necessary data about the patient, you need to return to the list of patients using the "Esc" button on the keyboard, or by clicking the "Back" button in the patient's card, or by clicking on the "List of events" link.
Next, you need to call the report “131/o. Information on medical examination of certain groups of the adult population (36AN). This can be done by clicking the "Reports" button above the list of patients, or by clicking the button in the upper right corner:


Figure 35 - Calling up reports
A window will open in which all fields are already automatically filled in, but are available for editing if changes are needed:


Figure 36 - Form for generating the report “131/o. Information on the medical examination of certain groups of the adult population (36AN) "
After filling in all the fields, click on the "Generate Report" button. A generated report opens in a separate browser tab, which can then be printed and signed.

Final actions

After you finish working in the system, click the "Logout" button in the upper right corner of the screen according to Figure 37. Close the Internet browser window and turn off the computer.

Figure 37 - Logout Button

emergency situations

In the event of a hardware failure, the normal operation of the system should be restored after the operating system is rebooted.
In case of incorrect user actions, incorrect formats or invalid input data values, the system issues appropriate messages to the user, after which it returns to the working state that preceded the incorrect (invalid) command or incorrect data input.

For successful development, you must have PC skills, as well as study this user manual.
Before starting work, you need to launch the application and pass authorization.

List of designations

Table 2 - List of designations

List of abbreviations

Table 3 - List of abbreviations

List of terms

Table 4 - List of terms

• No tags

(“EMK - workstation of a doctor of an outpatient clinic (polyclinic)”)

(brief description of features and functions)
Subsystem “Electronic medical record: outpatient clinic” MIS KAUS (mislpu. en) intended for:

• 
  automation of the workflow of an outpatient clinic (polyclinic) of a medical organization (MO);
• 
  automation of the workplace of a doctor in an outpatient clinic (polyclinic) of the Moscow Region at an outpatient appointment;
• 
  automation of a nurse worker of an outpatient clinic (polyclinic) of the Moscow Region at an outpatient appointment;
• 
  obtaining reports necessary for the work of a doctor in an outpatient clinic (polyclinic) of the Moscow Region;
• 
  exchange of information on the results of outpatient examinations with other subsystems of MIS KAUS.

To register EHR data in the outpatient polyclinic of the Moscow Region, the “Registration of Primary Documents” (REGDOC) module is used, the “AMB - POLYCLINIC (EMC)” mode.
It is necessary to fill in the user settings similar to the example below -

Subsystem “EMK - workstation of an outpatient doctor (polyclinic)”: offers the following possibilities:

1. 
   registration (adding, changing, deleting) patient data –

1. 
   registration of a new preferential prescription (federal and regional privilege) –

1. 
   viewing the list of preferential prescriptions (PR) and changing them -

1. 
   Viewing the list of patient's EMRs registered in the outpatient clinic (polyclinic) -

1. 
   Viewing the list of patient's EHRs registered in the hospital (day hospital) -

1. 
   printing of patient documents necessary for his service in an outpatient clinic (polyclinic) -

1. 
   registration of a new need for subsidized medicines (LPM) of a federal beneficiary, regional beneficiary, “refuseee” from the NSO -

1. 
   viewing the list and changing the need for subsidized medicines (LLS) of a federal beneficiary, regional beneficiary, “refuseee” from the NSO -

1. 
   functionality of a general practitioner (GP) –

ATTENTION!

For more information on the functionality of the “ARM VOP” popsystem, see the instructions contained in the file – ARM VOP - user manual.doc

1. 
   work in the mode “Electronic appointment with a doctor (examination, procedure)” -

ATTENTION!

More with popsystem functionality “Electronic appointment with a doctor (examination, procedure)” can be found in the instructions contained in the files:

- Electronic registry - user manual.doc

- Organization of work with the ELECTRONIC REGISTRATION mode MIS LPU.doc

1. 
   registration of data of outpatient examinations –

ATTENTION!

The list of examinations displays ONLY referrals to a doctor of the medical specialty specified in the settings for the user's workplace.
To fill in the outpatient examination data (referral), you must select ...


... and fill in the data -


ATTENTION!

It is assumed that the referral for an outpatient examination is carried out from:

- outpatient clinic registry (when making a patient's appointment with a doctor);

• 
  hospital (day hospital) (eg, upon admission of the patient);
• 
  outpatient clinic (for example, when a general practitioner (pediatrician, GP) sends a patient for examinations to “narrow specialists”).

If there is no data on the patient's referral (for example, when the patient self-refers to the polyclinic bypassing the registry), then the data on his outpatient examination can be entered in the same mode.
When filling in the following data:

• 
  Complaints
• 
  Anamnesis
• 
  Objectively (objective status)
• 
  Special Status (special status)
• 
  Treatment plan
• 
  Survey plan
• 
  Recommendations

ATTENTION!

Test templates for examinations of outpatient doctors can be. added and modified in the “MIS Administrator” (ADMINDOC) module. The addition of such templates must be done before the start of operation of the subsystem “EMC - Workstation of a doctor of an outpatient clinic (polyclinic)” by doctors.
After filling in the required fields, you must save the outpatient examination data (F2) ...


... and, if necessary, print the examination protocol using a printer on paper (for example, to add (paste) a paper protocol to the patient's paper medical record) -




After saving the outpatient examination data (doctor's confirmation), the data can be viewed in the “Results” mode.

1. 
   viewing and printing the results of outpatient examination data –

ATTENTION!

The list of results displays examinations of all medical specialties (without restrictions on the medical specialty specified in the settings for the user's workplace) against a blue-gray background - confirmed by the doctors who performed the examination of the patient.

1. 
   viewing and printing data of clinical and biochemical studies of the patient –

ATTENTION! The mode is available if the LPU uses the subsystem “LIS - laboratory information system” MIS KAUZ (mislpu.ru)

1. 
   viewing and printing data of functional examinations of the patient –

ATTENTION! The mode is available if the medical facility uses the subsystem “EMC - AWP of a doctor of functional diagnostics” MIS KAUS (mislpu.ru)

1. 
   viewing and printing of data of ultrasonic researches (ultrasound) of the patient –

ATTENTION! The mode is available if the subsystem “EMK - AWP of an ultrasound doctor” MIS KAUS (mislpu.ru) is used in the medical facility

1. 
   viewing and printing of X-ray examination data (RTI) of the patient –

ATTENTION! The mode is available if the subsystem "RIS - radiological information system" MIS KAUS (mislpu.ru) is used in the medical facility

1. 
   registration of data on preventive vaccinations -

ATTENTION! The user manual for working with the “Immunoprophylaxis” subsystem is contained in the file - User Manual for immunoprophylaxis.doc
18) adding, changing, viewing and printing outrageous epicrises on VK–






19) generation of reports -


Customer Support

mislpu @ yandex. en

The latest developments in information technology today find their application in various fields, including medicine. The main goal of introducing automated workplaces for doctors is the systematic application of IT methods, which are based on digital data processing, replacing lengthy processes of “manual” data management, and optimizing routine operations.

The principles of work of the workstation should be based on the principles of consistency, sustainability, flexibility and efficiency. This means that a certain doctor's workstation is a separate section of the general structural network, capable of being modernized, while remaining functional, independent of external or internal influencing negative factors. The effectiveness of the use of AWS implies the economic feasibility of implementation, the effective redistribution of functional responsibilities between a specialist and information technology.

The automated workplace of a doctor is a complex of hardware, hardware and software for the workflow associated with the performance of the professional duties of a specialist. The main purpose of the AWP is to facilitate and speed up the execution of a certain range of tasks by a doctor.

The main features of the doctor's workstation

The functionality embedded in the doctor's workstation may differ depending on the profile of the specialist, but the main tasks are basic:

1. Maintaining an electronic medical history, with the possibility of dividing the document into outpatient, dispensary, preventive, patient examination cards. Collecting, entering and saving in the database about the anamnesis, complaints, dynamic changes in the patient's health.
2. Fixing the treatment and diagnostic process, determining the diagnosis according to ICD-10.
3. Planning work, inspections, carrying out preventive measures (immunization, vaccination, etc.), monitoring compliance with deadlines.
4. Creation of individual programs of examinations and treatment.
5. Access to clinical protocols of diseases.
6. Issuance of prescriptions.
7. Issuance of sheets of temporary disability.
8. Output of the necessary data on paper.

Entering, correcting and saving information is carried out by the doctor himself, in the workflow mode, in template forms.

To protect the system from outside interference, an individual identification is provided for each doctor. This can be a digital signature, a password, or an access code.

Additional features of the workstation

For a doctor, AWP is a tool not only for automating the case histories of all his patients, from the first visit to discharge. The computerized AWP system becomes a functional assistant in keeping records and processing information, with the possibility of virtual interaction with other doctors and specialists, the accumulation and preservation of both one's own knowledge, developments and observations, as well as specialized data received from colleagues.

Along with the main functions, the doctor's workstation provides a number of additional features:

1. Access to reference information from databases of healthcare facilities, the Ministry of Health, medical research institutions.
2. Maintaining various reports, with the possibility of forming and grouping information by sites, departments of healthcare facilities, reporting periods.
3. Collection of analytical and statistical data on groups of patients - pensioners on the "D" register, beneficiaries, disabled people, etc.
4. Control of resources used in the treatment process (hardware and laboratory tests, medicines, availability of places in dispensaries, etc.).

The communication capabilities of the workstation ensure the rapid exchange of information, the sending of reporting documentation, and, if appropriate technical means are available, allow you to create and participate in video conferences, consultations, etc.

Hardware and software of doctor's workstation

The main requirements for the hardware of the automated workplace of a doctor are imposed on the technical and software components. So, AWP implies the presence of the following hardware:

• a computer unit with a different system architecture, which is adapted to the performance of certain tasks by the user (taking into account the power of the processor, video card, RAM, ROM, installation, if necessary, of an infrared port, network card, etc.);
• high resolution monitor with a diagonal of at least 19 inches;
• peripheral data input devices - keyboard, mouse;
• devices for outputting data to paper - a printer.

A doctor's workstation, as a rule, is equipped with network hardware tools for connecting to Internet resources and the general health care facility system - a modem, network adapter, network communication channels, etc.

If necessary, the doctor's workstation is provided with special devices, such as a digital photo and video camera, scanner, ADC.

Doctor's workstation software is a set of programs that provide efficient computational and organizational processes. The doctor's workstation software must meet the following requirements:

• convenient user interface of the program;
• Efficiency of data entry, with the possibility of error detection;
• accelerated search and processing of documents;
• exchange of information between workstations;
• the possibility of individualizing the program for a particular user.

It is important for doctors not to change the usual rhythm of work, therefore, training in the skills of using an automated workplace should not be long, time-consuming and take place without learning the basics of programming and other specific knowledge.

The use of an automated workplace by a doctor increases the efficiency of a specialist, increases the time for personal contact with the patient, while, taking into account professional employment, facilitates the process of improving specialized knowledge and improving qualifications.