Focus on: Clinical Records
Posted on 9 March 2022
Historically, the consultation room can be a difficult, dark environment for note-taking. This can lead to illegible handwriting and possibility of incomplete records due to simple human error.
Many optometrists aren’t computer experts and so a lack of keyboard skills will generally limit the speed of record entry on a PC.
Over time, every optometrist will develop their own routines, skills and specialities meaning that a fixed, ‘off the shelf’ clinical records computer system is far from a perfect solution.
Our Objective:
To create a module (part of the new Optisoft.NET system) to record complete patient examination history.
The module must be flexible and customisable enabling each optometrist to create their own perfect visit templates.
The module must be easy and fast to use, incorporating all input methods to work in the consulting room environment eg touchscreen, mouse and keyboard. It will also need to run on a tablet device for portability and more natural note taking.
A built-in record integrity checker should advise the optometrist if any information is missing.
The Outcome:
A completely customisable examination record system comprising of editable building blocks, created and maintained by each optometrist.
Each visit template comprises ‘Pathways’ to break up the examination (eg Preliminary, Refraction, Examination etc) and each Pathway can be sub-divided into ‘Pages’ (eg the Preliminary Pathway might have pages for Reason for Visit, General Health, Medication etc)
On each page, to assist with note entry, the optometrist can create their own ‘Option’ buttons to quickly insert the required results. In addition, a single click ‘copy from previous’ is possible for each page. For any other notes the optometrist can, of course, freetype.
To ensure records are completed in full and no information is missed, any page can be highlighted as ‘important’. If any highlighted page is not completed, the ‘Record Integrity Checker’ will advise the optometrist accordingly with visual cues.
Other features include a drawing tool with templates to create any sketches and the ability to attach any documentation or images.
The mailmerge feature enables the creation of documents such as handover sheets – perfect for providing your dispensing optician with all the details discussed during the sight test which can help result in a higher-end dispense and increased revenue.
Whilst editing referral documents, full access to the patients visit history is provided in the activity panel for reference. This helps make the creation of referrals fast and simple.
Optisoft.NET (including Clinical Records) can be run on any Windows device which now include tablets such as the Microsoft Surface Pro for complete flexibility.
