What Floor Is Mrs. Jones on, and What Does Her CBC Look Like
Contents
1. Ranking Status FIGURE 5 29 Diagno sisKeeper QuickProblems Reprinted with permission from patientKeeper Inc Select a QuickProblem OuickProblem List cy Pulrin Skin Signs Symptoms ic cosnoetid surgery FiGurE 5 30 Hierarchical Picker of QuickProblems Reprinted with permission from patientKeeper Inc patient in labor an additional problem is her previously diagnosed Group B Strep GBS infection This factor can be added as free text or can be accessed from a customized QuickProblem drop down menu under labor Figures 5 29 5 30 A great feature of this module is the ability to link to Task Keeper Use the box to identify tasks which then can be accessed from either TaskKeeper or DxKeeper Figures 5 31 5 32 To save a free text entry as a QuickProblem enter it Figure 5 33 and then click on the plus icon Figure 5 34 You ll be prompted to select a branch under which to store the new QuickProblem leaf Figure 5 35 Problem fee OuickProblem FIGURE 5 31 Link to TaskKeeper using the check box in the Problem Edit screen Reprinted with per mission from patientKeeper Inc Worthington J w Untiled ei Description O 5 Unfi j Start antibiotics FIGURE 5 32 View tasks from TaskKeeper module as entered in DxKeeper Reprinted with permission from patientKeeper Inc Chapter 5 Patient Records 109 Problem Problem Select Branch to tore Leaf oe QuickProblem Se pA2. mPI Edit details Picker New leaf Reprinted display Reprinted with per view Reprinted with permis with permission from patient mission from patientKeeper sion from patientKeeper Inc Keeper Inc Inc HANDS ON EXERCISE 5 3 FURTHER CUSTOMIZATION OF THE MPI FURTHER REFINEMENT OF THE CONFUSED WHERE ARE MY PATIENTS AVOIDANCE SYSTEM There are a few other ways to customize the mPI screen You can hide patients who you might have discharged but know might bounce back Figure 5 17 From the mPI screen highlight the patient you want to hide and then tap the Patients dropdown Select Un Hide Selection and that patient will be stored on a hidden list To recover them to the main screen go to the upper right dropdown Figure 5 18 and select Hidden While in the Hidden mPI screen selecting the Un Hide Selection will put that patient back in your active list Patients Configure About FIGURE 5 17 mPI Un Hide patients Reprinted ECESE A EE with permission from patientKeeper Inc fel xd 5 lS ed FIGURE 5 18 mPI Recover hidden patient Reprinted with permission from patient Keeper Inc Edit Filters i Filters consulting Critical Chapter 5 Patient Records Edit Filters i Filters Consulting Critical Discharged Inpatient Other Outpatient F GuRreE 5 19 mPI Add a filter Reprinted with permis sion from patientKeeper Inc Edit Filters i Filters con
3. Inc 130 A Price Send Patients ny Send Patients ny WHO To Send WHO To Send Bruce John Patients in hain view Select a Mew Set of Potients i Data To Send wl Data To Send W MoteKeeper W MoteKeeper EY RxKeeper BY RxKeeper EY Alertkeeper EY AlertKeeper EY OxKeeper EY OxKeeper FIGURE 5 96 Send Patients FIGURE 5 97 Send Patients WHO To Send Reprinted Select a new patient to send with permission from patient Reprinted with permission Keeper Inc from patientKeeper Inc Sending Patients In sending patients you have several options First make sure the recipient is using the same version of PatientKeeper Line up your IR ports Access the Send Patient s icon from the pull down menu see Figure 5 95 When you tap this icon you are presented with a screen giving you several options Figure 5 96 Send a single patient by selecting that person in the main mPI screen before pulling down the Send Patient s icon It will then be in the top window of the selections of WHO To Send Alternatively send all the patients in your mPI screen by selecting Patients in Main View or select individual patients by tapping on Select a New Set of Patients Figure 5 97 Select the box to send those patients Figure 5 98 or use a filter to select patients based on properties that you choose Figure 5 99 Send Potient s i Filter By Properties m Marne i Properties O Blakey Larr condition PY Bru
4. note types is shown to add a note choose Add see Figure 5 78 Location Fatients 4 labor a Worthington _ chest Porter Annie Shifflette Shirley surgery Anderson Famela r30 Preferences A QSOS FIGURE 5 76 NoteKeeper FIGURE 5 77 NoteKeeper Access from the mPI Toolbar Access the Edit Note Types Reprinted with permission feature Reprinted with per from patientKeeper Inc mission from patientKeeper Inc Writing Notes Chapter 5 Patient Records 123 Edit Note Types Edit Structure Mote Types Admit Mote HP Office SOAP Phone call Progress Mote Sections FIGURE 5 78 NoteKeeper FIGURE 5 79 Edit Structure Select Add to make a new Making a new note type note type Reprinted with Reprinted with permission permission from patient from patientKeeper Inc Keeper Inc An Edit Structure screen appears and you can choose the note type you want to make We re making an OB progress note Figure 5 79 For this note type we use the basic SOAP format Figure 5 80 but tailor it to labor ing OB patients Under Subjective we ve typed in a thumbnail of the patient Figure 5 81 For each section we can customize the prompts that will show up in the NoteKeeper view Now let s see how it looks as we use the template for Sally s admission From the Note Type pull down menu select OB progress note Figure 5 82 It then starts with the
5. page Reprinted with permission from patientKeeper Inc All Fatients 1 Location Patients 4 BIES Sample Sarah Forter Annie labor a Worthington Janet M304A verd Grace Had Remove Tetai fel xd 5 2 el 2 ed FiGurE 5 2 Mobile patient index screen patient census Tap on the menu bar at the top to access pull down menus Reprinted with per mission from patientKeeper Inc 100 A Price screen from which patient information is shared with other users via beam ing or printing Filters can be applied to the patient list so that only certain populations pop up for a given selection and patients can be sorted from this screen into various categories PatientKeeper is based on several modules centered around each patient from notes to labs to demographic data Everything is accessed from this mPI page Hands Off Logon Security Memory Use With all the Health Insurance Portability and Accountability Act HIPAA regulations and confidentiality needs of medical record keeping it s a good idea to make the use of your device secure PatientKeeper has a security code option From the mPI screen tap on the menu bar at the top Figure 5 2 circled to access the pull down menus Figure 5 3 Under Configure go to User Settings and type in your username You ll be queried about setting a password on next startup say yes and then the next time you boot up PatientKeep
6. per page i e Subjective Objective can house short bursts of text Select Button 1 and an Edit Button screen Figure 5 86a appears Put a in which can then be inserted into the programmed text of the section Figures 5 86b 5 87 Advanced Programming You ll note that in the Edit Qbutton screen there is an icon for inserting a Link To access this feature go back to the main screen of NoteKeeper and use the menu pulldown to change your preferences Figure 5 88 Select Advanced Mode to insert links from other modules into your notes Figure 5 89 Edit Note Types 979702 5 Edit Special Text gari aul re a FIGURE 5 88 Preferences Go to advanced pro gramming to add links to other modules Reprinted with permission from patientKeeper Inc i 126 A Price Worthington J Select Elementts Date Tests S902 5 55 pm Admit Hote O 829702 8 31 pr Ultrasnd e902 11 39 prmo Frogress Hote Preferentes wW Advanced Mode FIGURE 5 89 Preferences FIGURE 5 90 Qbutton link Check Advanced Mode Pick the test Reprinted with Reprinted with permission permission from patient from patientKeeper Inc Keeper Inc OB progress note 10 02 Section w Subjective 410002 3 31 am UltraSnd unsnansannnunnna Fansnsnnnunnunnsunnuunnunnnnsnnunnunnnnsmuunnnnnnnnnn nn eai da om c o FIGURE 5 91 Qbutton link Appearance in the Eeee Cealla TTS text Reprinted w
7. scrolling with the arrows Figure 5 46 Recording Vitals Tap New in the Vitalskeeper main module screen Figure 5 47 or tap on a recorded item to edit it in the Detail view Figure 5 48 Worthington J Date Ricur BPc Sr 10 02 20 Ser Oe 160 90 FiGcureE 5 47 Scroll with the arrows in VitalsKeeper Reprinted with permission from patientKeeper Inc Detail View aklai elol H FIGURE 5 48 VitalsKeeper Edit in the Detail View Reprinted with permission from patientKeeper Inc 114 A Price Getting There HANDS ON EXERCISE 5 8 LABKEEPER HAVING FUN BEING A GEEK Similar to VitalsKeeper this is one feature that will certainly delight the most obsessive compulsive medical students Of course if these data were uploaded automatically any physician would welcome it with open arms In the LabKeeper module patient labs can be entered into stan dardized panels which are then displayed by date from the main screen of the module Once again the information from this module will be accessible for the note writing function so you never have to write things twice From the mPI access LabKeeper from the pull down menu In the main screen labs can be viewed in simple list form Figure 5 49 or a more detailed view can be accessed from this screen Figure 5 50 This is a feature similar to the DxKeeper main screen To toggle between these simply click the box in the lower le
8. 5 What Floor Is Mrs Jones on and What Does Her CBC Look Like Today Patient Records on Handheld Computers AMY PRICE All of us have experienced the frustration of arriving at the hospital to make early morning rounds and spending considerable time trying to find where a patient is located and what their latest lab work shows Of course if it s the weekend this may be compounded by the fact that your partner s checkout list is completely illegible or worse lost somewhere in your trunk or laundry basket Now imagine doing all this without the assistance of caf feine as of course the coffee cart 1s closed on Saturday mornings As a patient care provider nothing seems more desirable than a hand held computer that manages all the data collection note writing and paper work hassles Now imagine being able to do all this while walking into the hospital from the parking lot this might allow time to stop somewhere for a cup of coffee Indeed current handheld technology begins to chip away at the current inefficiencies of medical record keeping and lays the groundwork for what is rapidly becoming a reliable secure timesaving development Certainly as institutional capabilities advance using these record keeping devices will be natural extensions of the electronic medical record There are programs for nearly every specialty and all the basic pro grams can be tailored to individual practice preferences The range of capac ity
9. A2 GuickProblem Sei Branches cy Fulm Skin Signs Symptoms Life Cycle Status i labor Classification cosmetic surgery Confirmation 5t Persistence Sto Ranking Status FIGURE 5 33 Store free FIGURE 5 34 Store free FIGURE 5 35 Store free text as a QuickProblem text as a QuickProblem text as a QuickProblem Reprinted with permission Reprinted with permission Reprinted with permission from patientKeeper Inc from patientKeeper Inc from patientKeeper Inc HANDS ON EXERCISE 5 6 PRESCRIPTIONKEEPER Billy everything is wrong who was just discharged from his most recent 200 day inpatient hospitalization is on the phone As the funny sinking feeling in your chest mounts he relates the story of how his overjoyed dog slobbered on the 30 written prescriptions you gave him and he needs them redone Smiling to yourself you open your handheld and remember how much you hated these calls 6 months ago Where do you want me to call these in This is a neat module that allows you to track meds link them to problem lists write prescriptions and record events such as when meds are stopped or started or when you last wrote a prescription Getting There From the mPI tap the RxKeeper icon circled and you come to the main page where all the medications are listed Figure 5 36 Worthington J Medications clindamycin 600 mg I gid Tylenol 325 mg FO FRA FIGURE 5 36 RxKeeper Toolbar icon and main s
10. By now all your colleagues may think you ve been reduced to a giddy hand held computer addicted fiend but wait until they see these other features 118 A Price Getting There Customizing Patients Location Patients 3 3 Centra Mobley L DowsS Blokey Lo Tower 7 Lichstein chest Forter An Shiftlette MedReparter a Exporter fy AlertKeeper 2 mP Dx eeper Rx Keeper LabKeeper E MoteKeeper ERLT DI Pestkheeper surgery Bruce Joh TaskKeeper Infokeeper Add J Remove Remove fy Se Procedurek y eS Procedurek T A deal Z 4p a DEF FIGURE 5 63 Procedure Keeper Access from the mPI pulldown Reprinted with permission from patient Keeper Inc Worthington J Date Proc Days ihe FIGURE 5 65 Procedure Keeper To Edit Procedures from the main screen tap New Reprinted with per mission from patientKeeper Inc Forter Annie Shittlette Shirley FIGURE 5 64 Access Proce dureKeeper from the Toolbar Reprinted with permission from patientKeeper Inc HANDS ON EXERCISE 5 9 PROCEDUREKEEPER ProcedureKeeper is a really useful module for those of you who need to keep track of your procedures It is customizable and can store a lot of detail Access ProcedureKeeper from the mPI screen Figure 5 63 Alternatively select it from the Toolbar at the bottom of the screen Figure 5 64 From the
11. Palm during the day use the Cache Framework setting but if you get into PatientKeeper and stay there while you re rounding the extra time on the front end to boot up the modules saves you a lot of time while you re in the program Programming Preferences This feature allows you to make advanced programming options in the NoteKeeper module linking data from individual modules such as vitals or test results to daily notes Access this from the NoteKeeper screen Figure 5 5 Use the Menu Pulldown Figure 5 6 and choose Options then Preferences Select the box for Advanced Mode Figure 5 7 then tap OK For the hands on exercises in the rest of this chapter we highly recom mend that you download a demo version of Patientkeeper if you have a Palm handheld of course and try these tasks yourself Patients fj 1 MedReporter Location Patients 7 a Exporter 3 CentralMobley L Hlertheeper Davis 5 Blokey Loen La Tower 7 Lichstein DxKeeper RxKeeper ds Lobkeeper AI estheeper 4 TaskKeeper Infokeeper Procedurek About ey Date Edit Note Types Edit S pecial Text Porter Annie Date Mote Type Preferences wW Advanced Mode iF Plonkeeper Aa x oO Z E QP vitalskeeper FIGURE 5 5 Programming in FIGURE 5 6 In NoteKeeper FIGURE 5 7 Preferences advanced mode Access this mode choose Preferences Advanced mode Reprinted feature via the NoteKee
12. a 39 yo WF admitted in active labor you only need to write in the name and age and tap QButtons for the rest If you can master the Special Text feature you don t even need to do that Editing Qbuttons Starting from the template for an Admit Note access the Qbutton edit screen from the section page e g progress record where you want the spe cific information Figure 5 85 For Sally Smith and other OB patients your ees Edit About Edit OButtons ress recor P Export to Memo Contractions See eee FIGURE 5 85 Edit Qbuttons Reprinted with permission from patientKeeper Inc pan w InsertText Edit Quick Text Buttons Button et Button 2 Button 3 Button 4 Button 5 Butt Edit Button FIGURE 5 86a Edit Qbuttons Enter free text for Button 1 Reprinted with permission from patientKeeper Inc Edit Quick Text Buttons Button 1 fetal movement vaginal bleeding male temale with post medical h presents to FIGURE 5 86b Edit Qbuttons Customize your text to speed data entry Reprinted with permission from patient Chapter 5 Patient Records 125 OB progress note 6 3 02 Section 4 ow Progress recore P Active fetal movement w insert Text oh FIGURE 5 87 Edit Qbuttons Main screen view of Qbutton text Reprinted with permis sion from patientKeeper Inc Keeper Inc QButton set can really make short work of note writing Up to 11 Qbut tons
13. c Inc 128 A Price Edit Special Text Special Text Links Label Assessment Link Description Text LIME gt Link 1 Age In Years Pt is lt LIMK gt r0 LINK admitted Link 2 Gender Link 3 Reason For visit Link 4 undefined FIGURE 5 93b Edit Special FIGURE 5 93c Edit Special Text Click lt LINK gt to add a Text Preset fields Reprinted link Reprinted with permis with permission from patient sion from patientKeeper Inc Keeper Inc 4 Summary Info is printable information that will be used by other programs For the preset fields the messages should already be set In the link we are creating Let s use a Get Data message that links additional diagnoses to the patient s assessment Figure 5 93e This takes you to a screen where you use the pull down menu to access the module to which you want to link Figure 5 93f Select DxKeeper then Selected Diagnoses After this you end up in the Special Text Links page again where Link 4 shows that it is Select Diagnoses Figure 5 94 Special Text Links Special Text Links Link Description Select a message Link 1 Age In Years Wlodule w RxKeeper Link 2 Sender Link 2 Reason For Visit Messages Link 4 lt undefined gt Selected Medications s Select hlessage Type Mesage Type w Select FIGURE 5 93d Edit Special FIGURE 5 93e Edit Special Text Select Message Type Text After choosing Get Reprinted with permission Data select
14. ce John surgery Potient Type O Lichstein Ben JTower T Relationship BY Mobley Letitid3 Central O Forter Annie chest pain ce O Shifflette Sh jchest pain ce O Worthington labor and deli E AE CID YE LF faH a Kfe ea DEER ERED efe ea Eee a5 Cee ee a5 space Csenduit Fiter 1 el aaea FIGURE 5 98 Send Patients FIGURE 5 99 Filter patients Choose by box or use a filter Use the filters you designated Reprinted with permission when you entered raw patient from patientKeeper Inc data Reprinted with permis sion from patientKeeper Inc Send Patients i WHO To Send Mobley Letitia Patients in Moin view Select a Hew Set of Potients Query You have received some PatientKeeper data via a beam Do you want to accept it Chapter 5 Patient Records Receive Potients w Patients O Forter Annie O Worthington O Mobley Leti O Blakey Lorry O Lichstein Be w Modules mF O MoteKeeper O Rskeeper 131 O Alertkeeper FiGurE 5 101 Receive Patients Select information to be received Reprinted with permission from patient Keeper Inc FIGURE 5 100 Receiving Patients Accept prompt Reprinted with permission from patientKeeper Inc Receiving Patients To get a patient summary from another user line up your IR ports and let the Palm handhelds shake hands It takes a few seconds to organize the data and then your screen will Query you about accepti
15. creen Reprinted with permission from patient Keeper Inc 110 A Price Medication Unit Route Pol pm sc FR y Freeladatalad Tab Problem ane FIGURE 5 37 RxKeeper Adding meds Note the mag nifying glass in the upper right Use that to get to the Medication w Re Analgesics Dos Antibiotics l a cardiovascular E Pulmonary Problem sae FIGURE 5 38 RxKeeper Pull down menus of common meds Reprinted with permis sion from patientKeeper Inc macro see Figure 5 39 Reprinted with permission from patientKeeper Inc Adding New Meds To add a new med tap New Med and an edit screen appears Patient Keeper has a great database of medications As you type several medica tion names will try to fill in your Rx field Just typing Amp gets you Ampicillin Figure 5 37 There is a drop down menu as well for common meds Figure 5 38 From the medication edit screen a searchable macro is accessed from the magnifying glass at the upper right Enter the med name to access the alphabetical list Figure 5 39a This is a handy dosing guide for many common medications You cannot add medications to the list but you can alter the dosing regimen to suit your style Let s say you generally order acetaminophen as a PRN for patients Under the standard listing the dose is 325 mg To change this to 650 mg go to the macro see Figure 5 39a and select acetaminophen Acetam
16. d specify other fields of information pertinent to that test Patients f 1 MedReporter Locotion Patients 8 a Exporter fy Alertheeper It oF DxKeeper Rx Keeper LabKeeper H SOTE DeF i TIRFeeper Infokeeper 3 Procedurek i Plonkeeper J Vitalskeeper chest chest generad labor d Fa xo 2S E FIGURE 5 72 TestKeeper Access from the mPI pull down Reprinted with per mission from patientKeeper Inc Uitrasnd Type Site Read by Follow up FIGURE 5 74 TestKeeper Add a new test and access the drawing feature Reprinted with permission from patient Keeper Inc Adding Tests Chapter 5 Patient Records 121 Lichstein Benj Date Test Surnrnary FIGURE 5 73 TestKeeper Edit a test Reprinted with per mission from patientKeeper Inc Uitrasnd Type Site Read by Follow up FIGURE 5 75 TestKeeper Use the drawing feature Reprinted with permission from patientKeeper Inc From the main module screen of TestKeeper select New and then pick a test from the pull down menu Figure 5 74 What follows is another of those features in this software that will delight the gadget geeks the drawing feature Figure 5 75 Power Users Tip Remember that as in the ProcedureKeeper module once the Test is added there will be a Summary field with a Hierarchical Picker in which you can enter other data For
17. e drop down menus for patient data entry has the capacity for customization An initial investment of thought and time will make later patient entry much quicker As you are getting started go through each of the fields and set it up according to your preference if you have the time You can now clean up your patient information display by selecting Edit Display to change the fields that are presented Figure 5 15 Let s change it to reflect what we really want to know By unselecting the fields you decrease unnecessary information and fields you have to scroll through Figure 5 16 Finally tapping OK on the Edit Patient display gets you back to the mPI where you see your list growing Hierarchical Picker Hierarchical Picker Acute Abdomen Chest Fain Cough Gl Bleeding Pre Op Check SOB Branch Pneumonia PINT Me oE Pe A tO ae Go A A Na a rent eee 0O alphabetize FiGurE 5 12 Hierarchical FiGureE 5 13 Hierarchical Picker New branch Picker New leaf Reprinted Reprinted with permission with permission from patient from patientKeeper Inc Keeper Inc 104 A Price Hierarchical Picker Edit Patient Edit Details View Field Hame Pf Admit Dote Birth Date i Gender Admit Date or BY Medical Record Number BY Reason For Visit BY Location O Financial Humber O Ethnicity O Discharge Date BY Admitting Physician O Attending Physician ACS F GuReE 5 14 Hierarchical FIGURE 5 15 mPI Edit FIGURE 5 16
18. e text is prompted by quick buttons of broad ranging text which you can then edit Figure 5 103 Included are all the general components of a history physical labs and notes Figure 5 104 It has numbered fields that you can customize to the right of the screen see Figure 5 103 134 A Price Quick Rounds Quick Rounds completes the field as an abbreviated program that lists patient names and diagnoses Figure 5 105 with an ICD 9 field and several Quick Rounds 2 records gt QUNDSHMAME 1 ROOMNO gt Hospit teL Bic out 326 Big Ho n im Bob Mattie Jones Record Edit Option 7 F3 A FIGURE 5 105 Quick Rounds PC program Patient list screen with filters Reprinted with permission from SuiteMD Chapter 5 Patient Records 135 Quick Rounds 2 records ok DOA 1 003 ACTIVE Mattie Jones Big House EM 326 Pneumonia Ceftriaxone azithromycin Or Mick hi Be Record Edit Option 7 iz a p F GuURE 5 106 Quick Rounds PC program Pull down menus grow as you use it more Reprinted with permission from SuiteMD other fields that you can customize It has a handy toolbar with search func tions and easy new patient entry When you enter data the pull down menu remembers what you ve entered before making data entry faster as you use it more Figure 5 106 Spend some time doing demos from these and other types of programs to see which one suits your needs and then st
19. e text screen by tapping the sign to the right of the center column or you can access a Hierarchical Picker and enter Chest Tube Attending Date Assistant FIGURE 5 69 ProcedureKeeper Screen view of the newly entered procedure Reprinted with Lo mk E l permission from patientKeeper Inc callie 120 A Price Hierarchical Picker Right Left Attending Date Assistant FIGURE 5 70 Procedure FIGURE 5 71 Procedure Keeper Tap Summary to Keeper Delete a procedure enter details of the procedure Reprinted with permission in a Hierarchical Picker from patientKeeper Inc Reprinted with permission from patientKeeper Inc common themes Figure 5 70 See the tutorial for the Hierarchical Picker Hands on Exercise 5 2 for more information Deleting Procedures Delete a procedure from the patient s list by selecting it from the main screen in ProcedureKeeper Tap the Menu pulldown then choose Delete Record Figure 5 71 TestKeeper TestKeeper is straightforward and allows you to input data that can be viewed in list format with a brief summary of results It can also be linked to your notes Getting There Select from the mPI toolbar or the pulldown menu to the bottom right of the mPI screen Figure 5 72 Customizing Tests Select New from the main TestKeeper screen and then select Edit Tests Figure 5 73 In the Tests screen you can add a new test an
20. e the identifiers shown from patientKeeper Inc to select them for your new filter Reprinted with permis sion from patientKeeper Inc HANDS ON EXERCISE 5 4 EXPLORING MODULES WHAT WHERE AND WHEN SANS PAPER The modules in PatientKeeper are a smorgasbord of data There are 14 pos sible features that you can display 8 of which can be accessed at any time from the toolbar at the bottom of the mPI Learning the symbols is fairly intuitive Edit the modules on the toolbar by visiting the Configure drop down menu Figure 5 24 Learn what the individual icons in this display mean Figure 5 25 by tapping the Information button i at the upper right corner of the screen Figure 5 26 Patients configure About PatientKeeper Modules amp Reoti Modules gt Lo 4 Name eee Framework Preferences o E User Settings O Exporter El User List ae Alertheeper El Column 3 Display Ej mP E Filters Wo DxKeeper El wo RxKeeper El w LabKeeper El W o NoteKeeper El Me Testkeeper El Of TaskKeeper 3 0 2 2 E ef x S18 el femal Ba FIGURE 5 24 mPI Edit FIGURE 5 25 mPI Edit module display Reprinted module display Reprinted with permission from patient with permission from patient Keeper Inc Keeper Inc Chapter 5 Patient Records 107 First column Checkmark Indicates the module has a tab visible on the button bar One can only have no more than tabs present on the button bar a
21. er you will enter a PIN that you need to remember PatientKeeper has a few additional preferences for programming and memory use PatientKeeper has an optional Cache Framework component that main tains information from the program in memory even when the program itself is not being used this increases the speed of starting the program but requires extra memory To use the feature access the Menu pulldown as above Under Configure go to Framework Preferences Figure 5 4 and select Cache Framework Edit PEK Framework Prefs Preference cache Framework O Open All Databases at Startup O Patients LO About _ Locg Modules labor Framework Preferences at User Settings L TE Column 4 Display Filters ef x1 SEG I FIGURE 5 3 User Settings FIGURE 5 4 Preferences for Reprinted with permission memory use Reprinted with from patientKeeper Inc permission from patient Keeper Inc Chapter 5 Patient Records 101 Power Users Tip This feature must be unchecked if you need to install a new version onto your Palm at a later time or if you want to add new modules as they come out The other selection in this screen allows all the modules to be booted up at startup making it faster to use the program once you are in it but slower to start This feature cannot be used if Cache Framework is enabled Power Users Tip If you toggle frequently between programs on your
22. first section that you entered in the note you created Figure 5 83 You can then manually insert her age and weeks of Edit Structure Edit Section Sections 1 Subjective 2 Objective 3 Assessment consistent witha wk ultrasound 4 Plan ddmitted in active labor FicureE 5 80 Edit Structure FIGURE 5 81 Edit Structure Add new sections and Customize the default text customize the wording Reprinted with permission Reprinted with permission from patientKeeper Inc from patientKeeper Inc 124 A Price OB progress note 10 02 Section w Subjective Worthington J w insert Text dh FIGURE 5 83 Writing notes See your default text and fill in the blanks Reprinted with permission from patient FIGURE 5 82 Writing notes Choose the new note type from the New Note menu pulldown Reprinted with OB progress note of3 o7 Section q w Progress reco Active fetal movement ae w InsertText dh FIGURE 5 84 Writing notes For next section use the arrows to advance Reprinted with permission from patient permission from patient Keeper Inc Keeper Inc Keeper Inc gestation By tapping the arrow in the upper right corner of the screen you advance to the next section Figure 5 84 In this screen you can use Qbut tons to speed up the text entry These are the fields at the bottom of the page that can be modified For instance you can set up your QButtons so that to say Mrs S is
23. ft corner of the screen Figure 5 50 New Patient Entry Data entry is very straightforward From the New Panel pulldown in the main screen of LabKeeper select the type of lab to be added Figure 5 51 Enter the data either by tapping on the part of the stick diagram where the information goes or by using the written prompts Figure 5 52 Once entry is complete click Done to return to the main screen Worthington J All Worthington J All Date Fanel 13 Corp Date Fonel 2 Comp m yrz zig Micro complete ar 21 44 UA complete ara 15 01 Chemistry Complete Prot Gluc gee 13 34 Micro Complete 22 12 15 Micro Complete fe 5 e ae on e 8 10 15 48 Chemistry Complete n A J ar 10 15 47 Chemistry Complete oe 15 47 Chemistry Complete gr 21 44 UA Complete w Mew Poel CH Hew Ponel FIGURE 5 49 LabKeeper Main module screen Reprinted with permission from patientKeeper Inc F Gure 5 50 Details View of LabKeeper Toggle using the icon in the lower left corner of the screen Reprinted with permission from patient Keeper Inc Chapter 5 Patient Records 115 Worthington J All Date Fonel 12 Comp ree 13 34 Micro Complete fee 13 15 Micra Complete S10 15 48 Chemistry Complete Complete Complete Complete Complete Complete Cr 1 1 Lr SE amp t FIGURE 5 51 LabKeeper Add FIGURE 5 52 LabKeeper a new lab Reprinted with Enter lab values on the stick pe
24. goes from a simple census and To Do list to widely configurable platforms with multiple preset pull down menus The specialty specific soft ware often includes a combination of coding and tracking as well Palm OS and Pocket PC units have many similar offerings For the pur poses of this discussion we ll look at one premade program for the Palm OS that is currently one of the most widely used It is freeware which is not an indication of its value in fact it seems to be among the most versatile programs available at this time We also show you a roundup of all the various programs available for Palm and Pocket PC handhelds so that you can get rid of your index cards and start tracking patients using your hand held computer 97 98 A Price The Basics of Keeping Track of Mrs Jones Formats for Patient Trackers There are two kinds of software for patient tracking stand alone programs or database templates The database templates are exactly what they sound like veritable tabulae rasae that require some work on the front end to make them what you want HanDBase is one of the easiest database pro grams to use for this type of project The software is available for both Palm and Pocket PC platforms and can be downloaded at www handbase com We show you in Chapter 17 how to build a simple procedures log using this program and you can also build your own patient tracker using the same basic skills Other database programs are co
25. inophen will appear in the medication screen from here tap the menu button Select Update Current Med Macro Figure 5 39b You then get a screen of categories to choose from that you can edit Figure 5 39c Select PRNs Tylenol Figure 5 39d The screen will revert to the Medication screen type in the dose you prefer in the highlighted dose field Figure 5 40 and this will be saved as your new acetaminophen PRN dose Deleting a Med Delete a current medication by selecting Delete Med Record from the screen in Figure 5 39b The program will ask you to confirm the deletion Figure 5 41 Search for Macro AZT 100 mg PO tid FIGURE 5 39a RxKeeper Search medications with a dosing guideline Reprinted with permission from patient Keeper Inc Medication Re Analgesics Bos Antibiotics Day hA Tapaa Problem p ae FIGURE 5 39c RxKeeper Update Med Macro Cus tomize PRN order set Reprinted with permission from patientKeeper Inc Medication w Re Tylenol Y Dose 650 w Freg oa 7 w Mote OZ O OO Start Day NA Duration Problem p SA FIGURE 5 40 RxKeeper Screen reverts to Medication screen Customize highlighted dose Reprinted with permis sion from patientKeeper Inc Chapter 5 Patient Records 111 EA Edit About Update Current Med Macro Delete Ved Mlacro Y Freg 74 Y Mote Start 7 Day H Duration Problem p ie FIGURE 5 39b R
26. instance if a V Q scan is ordered in the Edit mode 122 A Price Getting There you enter Probability and then in the Summary Hierarchical Picker enter Low Intermediate or High see the tutorial on Hierarchical Pickers earlier in this chapter HANDS ON EXERCISE 5 10 NOTEKEEPER GETTING THE MOST OUT OF DOING THE LEAST Notes in PatientKeeper are combinations of pull down menus and free text entry that can make quick work of admission and SOAP note writing once you ve customized your data sets All the data entered in other modules can be accessed from the NoteKeeper for your notes by using links Your free text entry can be augmented by Qbuttons which are customizable text buttons that allow common word entry by a simple tap of a button From the mPI access the NoteKeeper from the icon Figure 5 76 Editing Note Types From the main screen in NoteKeeper you can create and delete note types by using the Menu button on your Palm Figures 5 77 5 78 The program comes with the standard note types Admit H amp P and Progress Note Depending on your practice you can make detailed note types with links to data that are very specific to your work See the following step by step explanation Getting back to our patient Sally I think m in labor again Smith let s make a note format for her admission From the main NoteKeeper page tap the Menu pulldown Select Edit Note Types under Options A list of current
27. ith permission from patient w InsertText E Keeper Inc Link to other modules now that you re in Advanced Mode so that infor mation stored there can be easily and automatically inserted into your notes In the Edit Qbutton mode the link to the right of the screen allows you to select the module from which you want to link information In our case we want to link to an ultrasound so we select the test we want inserted into the text Figure 5 90 and when the QButton is selected again it inserts the summary of the test as well as when it was performed into the body of the text Figure 5 91 Power Users Tip Leave a space before or after the Qbutton text to avoid having to put it in yourself as you enter data Inserting Text Special Text Chapter 5 Patient Records 127 At the bottom of the section screens you have an opportunity to build an Hierarchical Picker See Hands on Exercise 5 2 on the Hierarchical Picker earlier in this chapter Click on Insert Text then Edit and use the trees to input information that you anticipate frequently entering This is a way to link other data such as first and last name age gender and billing information to Qbuttons not just items in the modules In the Edit Qbutton screen select Link Figure 5 92 and from the pull down menu choose Edit In the Edit Special Text screen now you can enter infor mation about fields you normally track Figu
28. main screen of ProcedureKeeper tap New and select Edit Procs Figure 5 65 Tap New and use the free text entry line to enter the procedure Figure 5 66 Tap Add and then you will be asked to enter Procedure Fields FIGURE 5 66 Procedure Keeper Use Add enter a new procedure in the Proc Field Reprinted with permis sion from patientKeeper Inc Chapter 5 Patient Records 119 Procedure Fields Procedure Fields Field Attending Text Field Type ow Text Field Type BERA FIGURE 5 67 Procedure FIGURE 5 68 Procedure Keeper Enter Fields regard Keeper Also track numeric ing procedure that you want fields Reprinted with permis to track Reprinted with per sion from patientKeeper Inc mission from patientKeeper Inc a field which is any information about the procedure that you wish to record such as Attending physician which is a Text entry Figure 5 67 or Date which is a Numeric entry Figure 5 68 Although you are editing your procedure list within an individual patient area the list is available for any patient in your census Entering Procedures Once you have entered your procedures and fields select the patient for whom you will record a procedure Tap New and select the procedure you ve done The screen will then come up with the name of the procedure and the fields that you already entered Figure 5 69 From here you can either manually enter data in a fre
29. module from from patientKeeper Inc which to link information Reprinted with permission from patientKeeper Inc Getting There Chapter 5 Patient Records 129 Special Text Links Special Text Links Select a message Link Description Link 1 Age In Years Link 2 Gender Link 3 Reason For visit Link 4 Select Diagnoses FIGURE 5 93f Edit Special FIGURE 5 94 Edit Special Text Pull down menu for Text Link 4 is now set for options from which to link Select Diagnoses Reprinted information Reprinted with with permission from patient permission from patient Keeper Inc Keeper Inc HANDS ON EXERCISE 5 11 BEAM ME UP Getting and giving sign out has never been easier or more confidential using the beaming function on your Palm No more papers to get lost no more wasted time looking for the shredder This feature allows your Palm to talk to another one equipped with the current PatientKeeper program and get its data When you beam you have the option of sending or receiv ing lists small groups or individual patients and then merging data to update patient progress With your infrared IR port you can directly beam to a printer if your institution has that capacity From the mobile patient index mPI access the beaming feature from the menu pulldown circle Figure 5 95 Patients Configure About FIGURE 5 95 Send Patients Menu pull down Reprinted with permission from patient Keeper
30. n a Palm OS and Pocket PC unit fairly seamlessly Unfortunately the programs themselves cannot be translated yet HanDBase one of the database template type programs is available on both the Palm OS and Pocket PC platforms and other ready made software for both platforms is increasingly available see Table 5 1 Other software available for Pocket PC includes Quick Rounds Noteworthy Clinical Companion 2 2 and MAME Symmins ia MRA 12345 CC SOB HPI Peis a 57_ yo male wl a PMH oF COPD who presents with a_z hour day week month history of shortness of breath The symptoms came on J He was last seen For i o Further pertinent history includes Relevant medications include The patient was seen in and care to this point has included FILE EDIT ADD CALC 2 Figure 5 103 DOXUITE program Quick text buttons prompt data entry Reprinted with permission from Cross Enterprises ON CALL INC DOXUITE Chapter 5 Patient Records 133 ANSWER Na Def Na Glu OSM PYR SYR FeNa IBW H20Def GFR LR ABG A a AG Ca alb CrEl CO Edit Return P FIGURE 5 104 DOXUITE program Data entry fields are shown Reprinted with permission from Cross Enterprises ON CALL INC DOXUITE We ll look at a few screens of two of these programs so you can see how they function DOXUITE is a collection of programs that links an information input program with a calculator and print friendly module Th
31. ng the informa tion Figure 5 100 Accept the patients and you will see a screen that lets you choose which patients you want and what information regarding each one you wish to store Figure 5 101 There are three ways of accepting data New Update and Data Only Figure 5 102 For the New option if you already have a patient in your list by the same name selecting New patient will put that patient on your list twice In Update mode the information in the mPI screen will be changed in addition to the information from the indi vidual modules that are selected In Data Only only the information from the individual modules will be added Receive Patients i Patients O Porte gem O Wort Update Moa Target O Mobl Dbata Oniy Mo Target O Blake steselact Target i be Mew _ F w Modules O MoteKeeper O Rskeeper O Alertkeeper F GuRE 5 102 Receive Patients Select mode of accepting data Reprinted with permission from patientKeeper Inc 132 A Price Pocket PC Software The offerings for Pocket PC s although fewer in number are very similar There are a few listings here with regard to patient records software Now that you ve worked your way through PatientKeeper these other programs will be a snap If you have a Pocket PC many of the documents for Palm software can also be read by the Pocket PC by purchasing some additional software Peacemaker is a program that allows you to transmit documents betwee
32. om the list Reprinted with permission from patientKeeper Inc Worthington J Chemistry Date 2202 15 01 id2 110 15 44 25 FIGURE 5 59 LabKeeper Graph icon upper circle accesses graphing function or click on Table to view table form lower circle Reprinted with permission from patientKeeper Inc Worthington J Chemistry Component w Ha 14 130 wee 16 45 w eee 15 01 FIGURE 5 61 LabKeeper Graph view Reprinted with permission from patient Keeper Inc Chapter 5 Patient Records 117 Worthington J Date 3 22 02 15 01 a 142 Status Complete w Click here for annotations FIGURE 5 60 LabKeeper Access graphing function from individual result view Reprinted with permission from patientKeeper Inc Worthington J Chemistry FIGURE 5 62 LabKeeper Table view Reprinted with permission from patient Keeper Inc function click on the graph icon from the panel view Figure 5 59 You can also view the graphing feature by clicking on the result itself the same page where you can highlight information and make annotations Figure 5 60 Finally the graph is booted up and Voila Impressive eh Figure 5 61 Table view accessed from the panel view will load a table with dates and results Figure 5 62 Even the infogeeks are impressed now right Printing Patient Data Print individual labs from the printer icon in the upper right of the panels
33. op wasting all that paper and time as you begin rounding with your handheld 136 A Price Summary Well now you have it You can finally get rid of those pesky index cards and start doing all your patient tracking on a handheld computer In this chapter we talked about the various options available for patient tracking and showed you how to use one of them in great detail Then we showed you patient trackers available for Pocket PC s and also an example of a simple patient tracker that could be used on both Palm and Pocket PC plat forms using HanDBase
34. otations Stock Phroses FIGURE 5 55 LabKeeper Click on the flag to mark it as important Reprinted with permission from patient Keeper Inc FIGURE 5 56 LabKeeper Use the annotation pulldown to make notes Reprinted with permission from patient Keeper Inc can click on the flag to note importance or use the pulldown at the bottom to enter any pertinent data Figures 5 55 5 56 Any lab highlighted as important will then move to the top of the list Figure 5 57 Deleting Patient Data Labs are also deleted from the panel view Click on the menu button Figure 5 58 to a pulldown where you can select Delete Panel Graphing Patient Data This module s most respectable feature is graphing but it also has a table form for those of you who remain unimpressed Can you believe it You can look at the sodium rise and fall in fantastic detail To use the graphing Worthington J All Date Panel 13 Comp EEU Edit Delete Panel z D m yrz ziqd2 Micro Complete Date 822 02 14 22 arz 1 01 Chemistry Complete 129 93 3 140 S22 13 34 Micro Complete 3 3 en a2 eee 13 15 Micro Complete eT S 48Chemistry Complete S10 15 47 Chemistry Complete oe 15 47 Chemistry Complete gr 21 44 UA Complete w Mew Ponel T see FIGURE 5 57 LabKeeper Main screen view with impor tant lab flagged Reprinted with permission from patient Keeper Inc FIGURE 5 58 LabKeeper Delete a lab fr
35. per Reprinted with permission with permission from patient module Reprinted with per from patientKeeper Inc Keeper Inc mission from patientKeeper Inc 102 A Price Getting There All Edit Patient Location Potients 3 Last Hame Forter Annie Worthing est Shifflette Shirley 0 DEBBIE a5 e lt E L ptc Pol f 78 310 Edit Displa FIGURE 5 8 Mobile Patient FIGURE 5 9 mPI Edit patient Index Add a new patient screen Reprinted with per Reprinted with permission mission from patientKeeper from patientKeeper Inc Inc HANDS ON EXERCISE 5 1 FROM NOTECARDS TO THE PALM OF YOUR HAND Your patient list is displayed in three columns location name and a cus tomizable column that you can change by using the pull down arrow this helps to avoid that confused where are my patients physician look After we try entering a patient we ll get to the more fun stuff Let s walk through adding a new patient first From the main screen of PatientKeeper select Add to begin adding a new patient to your list Figure 5 8 The Edit Patient screen appears Figure 5 9 where you can either type data in or use drop down menus that you have customized to enter patient information HANDS ON EXERCISE 5 2 HIERARCHICAL PICKER PatientKeeper uses the interestingly named Hierarchical Picker as the basis for editing and customizing pull down menus for each field In en
36. r Inc Medication Log i Dater Time Ewent SP S102 12 18 Script Dispensed FIGURE 5 45 RxKeeper Event log of an Rx dispensation Reprinted with permission from patientKeeper Inc It then automatically stores this as an event Figure 5 45 HANDS ON EXERCISE 5 7 VITALSKEEPER Although most practicing physicians rely on bedside charts and nurse s reports for vital signs hark back to your days as a medical student when not having the excruciating details of each and every vital would be your downfall during Dr Jones the nasty attending pimping rounds FIGURE 5 46 VitalsKeeper Reprinted with permission from patientKeeper Inc Chapter 5 Patient Records 113 MedReporter a Exporter fT AlertKeeper ane mF Dx eeper Rx Keeper LabKeeper MoteKeeper Fa Testheeper bA ToskKeeper e Infokeeper x 3 Procedurek DEF Worthington J Date Teur Se Oe Lc LT AT Witalskeeper Although you may not want to hand enter vitals in the program syn chronizing with a hospital information system to get this information is pos sible Recording vitals for your patients in this program serves many functions Once this information is stored it can be accessed by the note writing program and directly linked to your text Getting There The data entry page is found after tapping the New icon From the main vitals screen the date and data can be accessed by
37. re 5 93a In this instance these are fields that will automatically appear in the note that you are making age in years gender and reason for visit Let s add to the preset fields a link for other diagnoses Tap LINK which will add a link to the data Figure 5 93b Go to Edit Links in the bottom right of the screen Figure 5 93c Link 4 is undefined By highlighting Link 4 you are asked to Select Message Type Figure 5 93d This gets a little complex so hold on to your stylus The modules contain four types of data 1 Snippets are messages that are unchanging values for a given patient in this recorded event such as first name last name age gender Links 1 through 3 are snippets 2 Get Data messages come from ancillary data collected in the modules such as tests labs and diagnoses 3 Embedded modules allow you to type a new value into the note body which will then appear in the module that you linked to such as a new diagnosis that then ends up in DiagnosisKeeper as well Edit Quick Text Buttons Edit Special Text Button 1 Label Assessment Text LINK year old Pt is lt LINK gt ro SLINE admitted ultrasound history of cro Z Oe Le Edit Button FIGURE 5 92 Edit Special FIGURE 5 93a Edit Special Text Get there via the link in Text Click Edit Links to cus Edit QButtons Reprinted tomize Reprinted with per with permission from patient mission from patientKeeper Keeper In
38. rmission from patient figure or on the line Keeper Inc Reprinted with permission from patientKeeper Inc Editing Patient Data Once data are recorded editing is possible by selecting the lab to be edited from the main LabKeeper screen Once you are in the panel view click on the pencil icon at the bottom of the screen Figure 5 53 so that the red line is not apparent in the box this transforms the lab from a read only screen to one that can be edited Highlighting Important Labs While still in the panel view you can highlight or annotate labs that will make it obvious in the main LabKeeper screen To do this you can t be in edit mode so make sure that the pencil icon at the bottom of the screen has the red line through it From the Panel view click on the result you want to highlight Figure 5 54 this will take you to a Result page in which you All Worthington J Micro Date 72 02 21 42 Type culture Worthington J Chemistry Date 3 22 02 15 01 E idz 110 15 44 25 1 1 FIGURE 5 53 LabKeeper FIGURE 5 54 LabKeeper Pencil icon Change from Flagging important labs read only to edit mode by highlighting the lab Reprinted with permission Reprinted with permission from patientKeeper Inc from patientKeeper Inc 116 A Price Worthington J Worthington J Result i Date rreri 21 42 Date rreri 21 42 al Result Annotation GBS Status Complete w Click here for ann
39. s tests notes etc The personal version is a free download available at the PatientKeeper website www patientkeeper com Look for the demos they are a good introduction to the desktop systems that augment these packages tremen Desktop Palm Software name version OS PatientKeeper PocketPractitioner 2002 WardWatch Patient Tracker Mobile MedData Charts DOXUITE Quick Rounds Noteworthy Clinical Companion 2 2 Pocket PC Chapter 5 Patient Records 99 TABLE 5 1 Palm OS and Pocket PC Programs for patient record keeping Cost Site Free patientkeeper com 69 00 PalmGear com 29 95 pdaMD com Free handheldmed com 49 00 for medcomsys com handheld 599 00 for desktop 49 00 Handango com 19 95 medicalpocketpc com 69 00 medicalpocketpc com dously There is also a user manual that is downloadable in PDF format the following discussion should clarify much of their text Getting Started Logon Screens and the Mobile Patient Index Select the PatientKeeper icon from the application launch screen of your Palm Figure 5 1 The main page in PatientKeeper is called the mobile patient index or mPI which is your patient census Figure 5 2 From here you enter or select an individual patient and start rolling This is also the a E Addres Cale Card Into G Clack Cate Book Expense O kk HotSync Mail MedRepo O K Memo Fad Mote Pod Ps Ee FIGURE 5 1 PatientKeeper icon Palm home
40. sulting Critical 105 Discharged Discharged Edit A Filter Edit A Filter Mame DE Mame Unnamed Filter Column 1 Reason For Visit Edit Filter Froperties Column 1 Hame Edit Filter Froperties FIGURE 5 20 mPI Editing filters Reprinted with per filters Reprinted with per mission from patientKeeper mission from patientKeeper Inc Inc FIGURE 5 21 mPI Editing You can use the Filters option under the Configure dropdown see Figure 5 3 to change how you view your patient list Let s say you have a busy obstetric practice in addition to all your critically ill patients and you d occasionally like to see only your OB list From Edit Filters tap Add Figure 5 19 and then on the Edit a Filter screen highlight Unnamed Filter and type OB Figures 5 20 5 21 By editing the filter properties you can identify OB patients by calling them inpatient and other Figure 5 22 under the Patient Type drop down menu In the Edit Patient screen from the mPI all your OB patients can be entered as inpatient and other and they will be filtered as OB patients Figure 5 23 106 A Price Select Properties of Filter Edit Patient Properties P condition Y Patient Type O consult al EE Consult Critical aL Discharged v Other FIGURE 5 22 mPI Identifying FIGURE 5 23 mPI When patients for a new Filter entering patient data in the Reprinted with permission mPI us
41. t any time FIGURE 5 26 mPI Information about the icons Second Column Checkmark in the Edit module display Access from the indicates that the module icon in the upper right corner of the screen Peni saya ere TER Reprinted with permission from patientKeeper at Inc Power Users Tip Be careful when you re in this editing site the Remove feature deletes modules from the program and will clear the contents of any stored patient data in that module You can add the module back but this requires reboot ing the whole program HANDS ON EXERCISE 5 5 DIAGNOSISKEEPER THE PROBLEM LIST Sally I think l m in labor again Smith is finally admitted and is in active labor As you admit her use the DiagnosisKeeper to house an active problem list and link to tasks Figure 5 27 DiagnosisKeeper allows you to enter free text or to select from drop down menus Figure 5 28 For this roe ee OF Al Active Problem ar al Course Problems 23 A GuickProblem PStable GBS EStoble term gestation Life Cycle Status Classification Confirmation St Persistence Sta Ranking Status Quick Problem 4 FEA Felina FIGURE 5 27 Diagno FIGURE 5 28 New diagnosis sisKeeper main screen Tap New then enter free Reprinted with permission text Reprinted with permis from patientKeeper Inc sion from patientKeeper Inc 108 A Price Problem Confirmation 5t Fersistence Sta
42. tering patient data you first notice it in the Last Name field Let s try using it to customize the Reason For Visit field As you enter a patient s information select Edit from the Reason for Visit pull down menu Figure 5 10 The Hierarchical Picker screen is displayed which gives you several options Figure 5 11 For all customization the Hierarchical Picker allows both branches and leaves This field already comes with some preset leaves but we can try adding a branch and then some leaves of a common admission diagnosis Tap New Branch and use the free text site to enter a branch Figure 5 12 Pneumonia then shows up in the main Hierarchical Picker screen with an arrow to the right This arrow allows you Chapter 5 Patient Records 103 Edit Patient Hierarchical Picker Lost Home First Hame Birth Date Acute Abdo Chest Fain Cough Cl Bleeding Pre Op Check SOB Strok pee L O alphabetize Surgical A Edit Displa FIGURE 5 10 mPI Edit reason FIGURE 5 11 mPI Hierarchi for visit Reprinted with per cal Picker Customize your mission from patientKeeper data entry fields Reprinted Inc with permission from patient Keeper Inc to access the Leaves Tap Pneumonia again and then open and let s add some leaves Figures 5 13 5 14 Tap New Leaf from the main screen to enter a common diagnosis without subheadings such as Fever of Unknown Origin Each of th
43. vered in more detail in Chapter 11 The stand alone programs also run the gamut of flexibility and capacity for customization but are ready to use out of the box Many are specific to a certain specialty thus requiring little in the way of input for basic record keeping The more general patient tracking programs out there have similar format e A patient census e Individual patient data e Location e Medications labs vital signs studies problem list notes e To do list Depending on the other interfaces your handheld has and the hospital information technology infrastructure where you practice patient tracking on handhelds can range from complete manual input to generally pushed data that come magically from central databases every time you synchro nize or enter the hospital s wireless network if you re lucky enough to have one Many of these programs can be linked into any hospital s legacy infor mation databases for a small fee of course Table 5 1 lists some common handheld programs for patient tracking for Pocket PC and Palm handhelds Palm OS Software PatientKeeper Personal is a Palm application that is a fun and fairly straightforward system for managing your patient list It is one of the most versatile systems and the most complex It uses an open platform centered around a patient list that allows you to add programs from other devel opers It comes with modules that run databases for lab
44. xKeeper Select Update Med Macro Reprinted with permission from patientKeeper Inc WMedication Start sE Day Neh Duration Problem p ne FIGURE 5 39d RxKeeper Update Med Macro Choose PRNs Reprinted with per mission from patientKeeper Inc El a a a Rx Ampicilin a t A Y Dose Unit Route PO IM sc PR w Freg gd bid tid gid Confirm Delete Are you sure you want to delete this Ved Record FIGURE 5 41 RxKeeper Delete med from Macro Reprinted with permission from patientKeeper Inc 112 A Price Event Recording RxKeeper also has a log feature to record events such as prescription dis pensation or hold times Figures 5 42 5 43 The prescription feature Figure 5 44 lets you record when you ve given a prescription to a patient Medication Log i Dater Time Event Event Details Event Description Med started FIGURE 5 42 RxKeeper Event log for medications Access using the Log icon in the lower right of the Medica tion edit screen Reprinted with permission from patient Keeper Inc Medication ro es mT or Prescription i Rx Cindariycin Dose 600 Unit mg Re Fill FIGURE 5 44 RxKeeper Pre scription feature Reprinted with permission from patient Keeper Inc Medication Log i Dater Time Ewent r d r z 15 00 Med started FIGURE 5 43 RxKeeper Medication Log screen Reprinted with permission from patientKeepe
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