The contact list shows all past consults, letters, pathology etc.

Transcription

1 BASIC CLINICAL OPEN A PATIENT S CLINICAL RECORD Method 1: Select the patient s appointment and click the stethoscope icon Method 2: Go to Open > Patients, enter the patient s name and click OK, and then double-click on the correct patient from the displayed results to access the clinical window. CONTACT LIST The contact list shows all past consults, letters, pathology etc. View all Clinical Contacts (this is the default view) View Consult Notes View Attachments and Scans View Letters and Op Reports View Incoming Electronic Correspondence View Procedures View Pathology/Radiology results View Patient Notes (created via Notes in the Demographics or Tools > Add Document in the Clinical window) View Workcover claims only To view the content of a specific contact, click once on the contact in the Contact List and it will show in the Display pane. To edit a specific contact, double click on it. The original item will open. Make the changes and save. Note: Never make changes in the Display pane as the changes won t be saved. Note: If the file is an attachment such as a PDF document or image, double-clicking will open the file outside of Genie. Page 1

2 CONSULTS CREATING A NEW CONSULT RECORD To create a new Consultation record, click on the button Specify the reason for the visit using the Select a Problem dropdown menu. Build your menu of common problems by using the Add to menu option. To add a problem for only the current patient, select the New Problem option. Enter the details of the day s consultation by typing directly into the History, Examination, Diagnosis and/or Treatment Plan field. You may also use Macros and/or Checklists. Note: You can double click on the primary problem to populate it under Diagnosis. USING MACROS Macros are codes that Genie replaces with a predefined word, sentence or paragraph when typed. Macros can be added and modified by clicking the Macros button at the bottom of the Consult window. To use a macro, type the code followed by a space or use the next to the headings and select from the list. USING CHECKLISTS Checklists record common Q&A or standard tests applied in specific consultations, e.g. pre/post-op, initial consults. Checklists must be created by the user or pre-configured checklists can be imported via Special > Software Updates in the Checklists tab. To use a checklist, select it from the dropdown. Saving the completed checklist puts the data into the chosen field (History/Examination/Treatment). Page 2

3 ADDING MEASUREMENTS Click the above the measurements section in the consult window to open a new measurements window. Complete the relevant fields and click OK. Each entry will display as a row in the measurements table on every consult window. To edit the entered measurements, double click on the measurement in the bottom right of your consultation record. SAVING AND EDITING CONSULT RECORDS Make sure you save your completed consultation note by clicking. Your completed consultation note will appear in the contact list denoted by. You can re-open an existing consult note by double clicking on the item in the contact list. You can also Edit a consult note by clicking the Edit Cons button, however this will create a new consult if there isn t an existing consult note to edit. Note: If the consult was created before today, Genie will let you append to the item but not change the existing content. PRESCRIPTIONS ADDING A NEW PRESCRIPTION FROM EITHER THE MAIN OR SUMMARY TAB Click the to the right of to open the Prescription window. Type the first few letters of the medication. Double click on the correct medication from the displayed list. The selected medication will populate the Script field. Note: If you do not have MIMS installed you will need to add your medications using the button in the Prescription window. Enter the Dosage (e.g. 2), Frequency (e.g. bd), Instructions (e.g. with food) and Repeats. The Category field determines how long the medication will remain on the current medications list (e.g S = 30 days, C = 12 months). Press the button to add this medication to your list of commonly prescribed medications. Click Save to create the prescription record and return to the patient s Clinical file. Page 3

4 USING THE QUICKSCRIPTS MENU The next time you wish to prescribe this same drug for any patient, if you clicked you ll be able to select it from the QuickScript dropdown. To delete items from this menu, hold the ALT/Option key on your keyboard and click on the entry you want to delete. PRINTING PRESCRIPTIONS New scripts for this patient are automatically ticked in the Print column. Click the to print any ticked items. For Authority medications you will be prompted to phone and enter the Authority number at the time of printing. You can adjust the Dose/Frequency/Instructions manually by slow double clicking in the respective columns i.e. click once to highlight the script and then click again on the value you intend to change. To reprint a prescription, manually tick the box in the Print column next to the medication you wish to re-prescribe, then click ADDING AN EXISTING PRESCRIPTION To quickly add medications the patient currently takes to the list that were not prescribed by you, hold down the ALT key while you click to the right of PATHOLOGY AND RADIOLOGY PATHOLOGY REQUESTS Click the at the top of the patient s clinical window. Select the correct laboratory using the Laboratory dropdown menu. Double click on each of the tests you wish to order or select a preconfigured set of tests using the Sets dropdown. Tests will be inserted into the central text box. Click on the Print button to print the Pathology request on the laboratories pre-printed stationery or tick the box next to Use Plain A4 to print on plain A4 paper with your letterhead. For commonly ordered sets of tests you can create a Pathology Set. To create a set, add all required tests for the set into the request box. Select Save Set... from the Sets drop down menu and give the Set a name. Pathology Sets are not user specific. RADIOLOGY REQUESTS Click the at the top of the patient s clinical window. Double click on each test you wish to order from the column on the left-hand side of the window, and then double click on the location from the column on the right-hand side of the window. Alternatively, type the tests manually in the central text box. Select the radiology provider from the dropdown in the middle of the window and the corresponding template you wish to use from the Use Template dropdown menu and then click the Print button. REPRINTING REQUEST FORMS To reprint a request form, go to Open > Investigations Audit. Double click on the request and click the Reprint button. Page 4

5 PROCEDURES To add a new procedure, go to Tools > Add Procedure. The minimum information required is a procedure name in the Procedure field. If you wish to leave the procedure as pending while the patient decides, tick Needs an Appointment in the lower right corner and click Appointment Pending. If you adjust the date and time for the admission and procedure, you will be given the option to tick Needs an Appointment and click Make Appointment, which will create a matching appointment in the Appointment Book. CREATING LETTERS To create a letter addressed to a GP or Specialist click on the red quill icon patient s clinical window. at the top of the To create a letter to the patient e.g. Medical Certificate, click on the merged letters icon of the patient s clinical window. at the top INCOMING LETTERS A letters. button will appear in your navigation palette when you have unlinked Double click on the first letter in the displayed list. Genie will match the patient based on the Surname and the first 3 letters of the First Name. If Genie cannot find the patient in your database, you can create a new patient record by using the icon. Demographic information will be populated based on the information in the letter. After the letter has been reviewed, click on letter. the icon Genie will automatically display the next INCOMING RESULTS A button will appear in your navigation palette when you have unlinked results. To check your results, click on the Results to Review button. Double click on the first result in the displayed list. Genie matches the patient based on the Surname and the first 3 letters of the First Name. If Genie cannot find the patient in your database, you can create a new patient record by using the icon. Demographic information will be populated based on the information in the result. After the result has been reviewed, click on the Link icon. After clicking the Link icon, the Action List window will appear. Page 5

6 If required, select a comment from the list or manually type a message at the bottom of the window. If Add to Action List is ticked, the result will be moved to the Action List (Open > Investigations Action List) after linking so that the receptionist/practice nurse can go through the Action List taking whatever action necessary for each result. After linking a result, Genie will automatically display the next result. REVIEWING LETTERS A button will appear in your navigation palette when a letter has been created for you to review. To check your outgoing correspondence, click on the Letters to Review button. Double-click on the first letter in the displayed list. Once you have reviewed and/or corrected the letter, click the Reviewed checkbox at the top. Genie will automatically display the next letter in the list. TASKS Add a task for a patient by clicking on the Other or Checklists/Script Archive tab. Click the in the Tasks section to create a patient-related task for yourself or another member of staff. Alternatively, navigate to the Open menu and click Tasks to add a non-patient related task. HELPFUL TIPS CONTEXTUAL HELP Navigate to the File menu and select Help to open the online manual relevant to the area of Genie you are in. You will need an active internet connection to access the online manual. COPY MENUS If a new practitioner enters the practice, to save them having to build their own menu you can copy existing menus such as Current Problems, Past History and QuickScripts from an existing user. To copy the menus from another user go to File > All User Preferences. Double click on the new practitioner s name, and go to the General tab. Click Copy Menus, and select the doctor whose menus you intend to copy. This guide is not designed to replace formal user training. For more information, please consider your support options: Genie Manual Special > Online Manual Group Training Courses Visit: Genie Support or support@geniesolutions.com.au Customised On-site Training Visit: Page 6