Recording and Managing Clinical Data

 

The recording and management of most clinical data is perform via the Clinical Window, and on a patient-to-patient basis. Information management en-masse (for example, printing Recall letters to patients) is generally performed from the MedicalDirector Clinical front screen.

From within the Clinical Window you can access clinical modules from the menus or buttons, or select others from the various tabs, all of which can be seen in the following image.

By clicking at the top-left of the Clinical Window, or pressing F3 on your keyboard, you can add a new item to the patient's record, dependant on the currently-selected tab. For example, with the Current Rx tab selected you would add a new prescription - with the Past History tab selected, a note about the patient's clinical history.

Conversely, clicking or pressing the Delete key on your keyboard removes any highlighted clinical information from the patient's record. Keep in mind however that some information cannot be removed. For example, you cannot remove information from a patient's previous Progress Notes.

When deleting some forms of data (for example, from the Current Rx and Old Scripts tabs), you will be prompted to enter a reason for deleting it. This information is stored in the patient's Progress Notes and in the case of prescriptions, a list of deleted medications. This feature can be de-activated via Prescribing Options.