Documents Tab

 

MedicalDirector Clinical provides a facility for importing external documents and third-party files into the database and storing them with a patient's record. Such 'documents' can include spreadsheets, word processor files, text files and images; essentially, you can import any document format you desire, and (provided you have the associated 'source' software installed) open these documents via MedicalDirector Clinical.

MedicalDirector Clinical provides a TWAIN-compliant interface for scanning external documents (such as X-Rays or patient letters) and importing ECGs created by third-party systems. Via this technology, MedicalDirector Clinical can also accept image data from devices such as digital cameras. MedicalDirector Clinical itself does not contain a scanning utility. Rather, when you perform a document scan from within MedicalDirector Clinical, the third-party software you use to perform scans (normally supplied with your scanner) is activated automatically, and it is this software that performs the scan.

The MedicalDirector Clinical definition of 'documents' should not be confused with 'letters'; in MedicalDirector Clinical terms, a document is an imported file, whereas a letter is correspondence created with the MedicalDirector Clinical Letter Writer. That is not to say you cannot scan or import a letter you have received in hardcopy form. In fact, letters (and other such files), when added to a patient record in this way, can be saved to either of the Correspondence, Documents, Letters or Results tabs within the patient's record.

Because of the potentially-sensitive nature of the content that can be saved to this tab, it is not accessible to users with basic security access. Such users can scan/import via the Scan/Import Correspondence window. See also Document Management Scenarios.


o       By default, items are displayed in order of date collected.

o       Rearrange the column order by clicking and dragging a selected column, and dropping it to a new location.

o       Sort the list of Results by clicking on any column heading. The sort order of a column is indicated via the direction of the icon.

o       Double-clicking a record opens the record in a separate window. Previous/Next buttons on this latter window allow you to browse through the list of records.

o       Multiple records can be selected simultaneously using the CTRL or SHIFT keys, as per standard Windows functionality, or by clicking the Select All link.

o       Simple/Advanced filtering can be applied to this window. In the example above, the Subject column has been filtered;


See Filtering/Searching Correspondence Records for more information.

 

o       Details of a selected document are displayed in the lower section of this window.

o       If you sort the records on this window, including the repositioning of any columns, this sort order is retained upon closing the patient's record.

 

Items of interest on this window:

Note that the range of option available to you will be limited by the level of access you have.

Upper Section

Checked By

The name of the user who checked the result in the Holding File.

Clear Filters

Clears any filters you may have applied to this window. This option will be greyed-out if no filters have been applied.

Clear Search

Undo any keyword search you have performed.

Comment

Details of any comments recorded.

Complete

Indicates the final in a series of results.

Date Checked

The date on which the result was checked in the Holding File.

Date Collected

The date on which the sample was taken from the patient.

Date Created

The date on which the result was created by the laboratory.

See also 'Date Requested'.

Date Notified

The date on which the notification for this test was made.

Date Requested

The date the practitioner requested the test be performed.

See also 'Date Created'.

Delete

Click to delete selected documents.

Document Details

Click to edit the details of a selected document.

Hide/Show Preview

Hide or show the preview pane.

Import

Click to import  a file directly into the Documents tab.

Move Location

Click to move selected documents to a specific tab within the patient's record. You can select from the 'Documents', 'Letters' or 'Results' tabs in the Clinical Window, or the ECG tab of the Tool Box.

Notation

Details of any notation that has been made.

Notified By

The name of the user who recorded the notification.

Open Externally

Opens the selected document in the default third-party application, for viewing externally to MedicalDirector Clinical. Only available to records that must be opened by a third-party application.

MyHealthRecord Activity Date

The date on which My Health Record activity was performed.

MyHealthRecord Status

The current status of any My Health Record activity performed  on the correspondence item.

Preview;
Full, Bottom, Right

Controls the display of the preview pane, which contains selected document's details. Options are 'Full', 'Bottom', and 'Right'. The image above shows that 'Bottom' has been selected, and the details of the selected document are visible in the lower half of the window.

Print / Print To

*Include Patient Header

Prints every page of every multi-page document within every selected record;

  • Print: Prints to the Letter Writer printer.

  • Print To: By clicking the next to the Print button, you can specify where you want to send the print job by calling the Windows print dialogue box.

 

The 'Include Patient Header' option will print the patient's demographic data that appears at the top-left of an item, as shown in the example below. Most results include this information already, so it would normally be unnecessary for you to select this option. You can set whether this option is active or not by default via Investigations Options.

Print List / Print List To

Prints a list of selected documents. Note that the details of the selected documents are not displayed on the printout.

  • Print: Prints to the Letter Writer printer.

  • Print To: By clicking the next to the Print button, you can specify where you want to send the print job by calling the Windows print dialogue box.

Recipient/Doctor

The name of the recipient of the test.

Refresh

Click to refresh the list of documents.

Remove from MyHealthRecord

Click to remove the selected document to the My Health Record system. You can also right-click a selected document to access this command.

Scan

Click to scan a document directly into the Documents tab.

Search

Perform a keyword search of the list of records.

Send SMS

Send an SMS message to the patient associated with the selected document.

Send to MyHealthRecord

Click to send the selected document to the My Health Record system. You can also right-click a selected document to access this command.

Sender/Provider

The name of the laboratory that conducted the test.

Source

E.g. SDI, imported, scanned.

Subject

The name of the test ordered.

Type

Indicates the type of test (e.g. Pathology, Cytology etc)

User Name

The name of the user who imported the file. For SDI results, the name of the computer on which the file was imported.

Zoom

Select a zoom option fro the drop-down list provided. Only available to records that can be zoomed, such as photographs.

 

Lower Section

Action

Record/Edit an Action against a selected record.

Add Recall

Click to add a Recall for the patient. ERROR: Variable (Recall_Management) is undefined.

Assign / Reassign Patient

Click to select a different patient to assign selected records to.

Assign / Reassign Recipient

Associates the selected record with a specific recipient.

Audit History

Toggles half of the viewing area to display an audit trail of changes made to a selected document.

Notify / De-notify

Click to indicate that the patient was notified about the selected document. This may be used if you have scanned or imported an Investigation Result into the list of documents, for example.

Previous / Next

Click to scroll through the list of documents.

View Signature

Click to view the digital signature of any encrypted document you have received via MD Exchange.