Examination

Examination 001.jpg

The "Examination" tab allows to enter the result of examinations conducted by a doctor during the visit. For legibility, information is not entered in the form of description, but by a properly defined template form or template of document. The doctor by himself creates templates of forms / documents to entering examination results. Because the range of input information depends on the type of visit and specialties, so you can create many different templates (the way of their creation is presented in the section “Defining Documents” and “Document templates”). In the "Examination" tab there can be visible:

  • templates selecting field – field helps doctor to select one or more templates of forms / documents to fill during the visit (field is not visible in case of realized visits)
  • form/ forms to fill – forms corresponding to selected templates made for filling during the visit.

To complete the form, click on the "Select template" field. The list of available templates of forms / documents will develop (document templates has the "(PDF)" endorsement; templates in the patient's language are additionally marked with "+"). You can select a template by clicking on the appropriate template (selected templates appear in the "Select template" field). If there is only one examination template and the surgery room configuration indicates that it is to be automatically selected or if the definition of the examination form template indicates that it is to be automatically selected, then such a template is selected systemically at the moment of entering the "Examination" tab.After selecting a template / templates, click the "+" sign to show in the examination tab a form corresponding to these templates. Over each form there is the title bar with a field with the name of the form (to edit), the template name and buttons of saving form with floppy icon and with an "x" to remove a form. Attachments can be attached to each template (the "Attachments" section is visible under the template form). You can attach one file or several files at once and the attaching operation can be performed multiple times (to attach subsequent files). After selecting the file / files from the disk, click the button with the "+" sign next to the file attachment field. When you click this button, a progress bar for uploading the file to the server will appear for each file. One have to wait for the files to be uploaded to the server. When the file is uploaded to the server, the progress bar disappears and the file name appears in its place with the selected checkbox. If the file was attached by mistake, then the checkbox should be unchecked so that the system ignores the given attachment when saving the data. After saving an interview in the header bar appears the button with printer icon to print a document. If attachments have been attached to the document template, then those from the attachments, which are PDF or JPG files, are automatically attached to the document printout. PDF files are attached in their original format, JPG files are added to the printout on an A4 page with half-inch margins at a minimum resolution of 300 dpi. When you have selected more than one template there is visible only one form with header bar and for the other forms there are only header bars – by clicking on the header bar you can switch between following forms to fill out. The text fields in the forms corresponding to document templates have a built-in content filling control indicator: if the content entered in the text field takes up less than 90% of the space allocated to it in the document template, then the background of the text field is white, if it takes 90% to 95% of the space - the background changes to yellow, if it occupies between 95% and 100% space - the background changes to orange, if it takes more than 100% space - the background changes to red. After filling / modifying form, the examination should be saved by pressing the button with floppy icon on the header bar of form. In case of visits / surgeries realized by more than one person from staff, each person realizing the visit will be seen examinations made by themselves and by other people realizing the visit but save and delete buttons will be available only at the examinations entered by himself.

If the diagnostic imaging module has been enabled in the jHIS system, the "Diagnostic imaging" section appears at the bottom of the tab. This section contains a form for issuing orders for diagnostic imaging examinations, and a list of ordered diagnostic imaging examinations is visible below the form. Each order on the list has an icon indicating the current status of the examination: orders not yet completed are marked with a red icon, and those already completed are marked with a green icon. For each examination on the list, the system automatically (every 15 seconds) checks whether the results have already been received from the diagnostic imaging device, and if so, changes the status icon and downloads the results to the "Imaging diagnostics" section.

To issue an order, one must indicate the device on which it is to be performed and the type of examination to be performed, and then click the "Send examination order to device" button. The order issued in this way will appear on the list below the form (and on the diagnostic imaging device it will become available on the worklist). To view the details of the examination, one has to click on the bar with its name. This will expand the panel with information about the examination and its results. If the examination has not yet been performed, then under the examination information table there will be displayed the message "Waiting for the examination to be performed" and the "Cancel examination order" button, clicking which will delete the issued order (e.g. in the case of its erroneous issuance).

If the examination has been performed, then links to DICOM files containing the examination results are displayed under the examination information table, and JPG images extracted from the given DICOM file are presented under each of these links. Each of these images has a checkbox that allows you to attach the image to the visit summary printout. Below the image data, there is a box that allows one to enter a description of the examination result. After selecting the JPG images that are to be attached to the visit summary and/or entering a description of the examination result, this information should be saved by clicking the "Save" button.

The "Back" and "Next" buttons visible at the bottom of the tab allow you to switch accordingly to previous and next tabs in the visit card.