Medical Records Module

The Medical Records Module is the core of the MYCURE Clinic Management System wherein users can access the list of their clinic’s patients as well as their medical records which are handled with the utmost caution and security. This is important most especially in making sure that the clinic’s medical records are kept safe and protected, as well as true to the doctor’s consultation and interpretation to deliver quality medical care and attention.

This module has five primary users namely Head - Medical, Doctor, Therapist, Head - Nurse, and Nurse. Each of these users have their own role and privileges to ensure the patient’s utmost health and the security of their medical records. In this tutorial, we’ll discuss the users whose task is to oversee the medical records department and ensure the patients get the proper healthcare: Head - Medical and Doctor.

Head - Medical
The head of the medical records have the full access to the medical records module and can access reports in read-only mode produced from Laboratory, Imaging, PME and Dental modules. Medical Records Head users oversee all the transactions pertaining to patients’ records which is important in ensuring security and privacy of medical data.

Similar to the Head of Medical Records, Doctor users also have full access to the medical records module and can read clinic generated reports. These read-only reports are important for Doctor users in completing their assessment for each patient in a well-informed manner.

Quick links that you may want to check:
Getting Started for Doctors
Getting Started for Secretary
How does the nurse add vitals for consult patients?
Viewing your Nurse's EMR Wrap-Up
How to update your PTR number
Manually Adding Patients

Medical Records
In records management, users can CRU a patient profile, archive a patient and their corresponding record, view previous encounter, and CRUD other relevant medical records.

To Create, Read, Update, and/or Delete (Archive) a patient record, simply go to EMR > Patients wherein users can see the list of all the clinic’s patients. Select patient to view their record.

Clicking the edit icon beside the patient’s name. This will show an option to edit the patient’s details, view the medical record summary, and archive the patient and their record will appear. Click the Edit Patient option to be redirected to the patient’s details, Medical Record Summary to view the records of the patient, and Archive Patient to move the patient record to the clinic’s archives.

Medical Form Templates
These form templates refer to the necessary documents that the clinic, doctors, and patients need in order to carry out proper healthcare procedures. To use this, go to EMR > Current Encounter > Attachments Tab > Attachments or Medical Forms.

Click “Add New” to add a new entry. There, users can upload photos from their computer or click the “Draw” button and then a prompt will appear asking to either upload their own template to draw on or choose a default template from the system.

Once a template is chosen, users can choose the pencil color and pencil size. To erase the drawing, simply click the “Clear Drawing” button. To save, click “Save Drawing”.

There are four types of forms to be filled out by the users namely the Medical Certificate, Fitness Certificates, Questionnaire, and Waiver.
Once “Add New” is clicked for each of these, users will be asked to choose a template that was previously set in the Administrative Module > Forms. Click the desired template, input the required details, and then click “Save Records” to finalize.

Medical Record Access
The medical records access refer to the managing of which users can see certain medical records of the patients. This pertains to medical information that are sensitive and can be used against the patient in malicious ways. This is accessible by clicking the “More Options” button on the upper right corner of the selected medical record field.

Medical Record Analytics
The medical record analytics refers to the number of patient visits as well as their disposition summary. This is found on the Clinic Dashboard.

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