Customising Clinical Findings Forms
Capable 21C supports a powerful system for the recording and reproduction of clinical findings. The system is based upon a series of numerically coded entries that a practitioner can select and quickly assemble into a complete report of findings. This article describes how to customize those components to support any individual office’s requirements.
The Clinical Findings tools within Capable 21C are incredibly flexible and powerful. This also means that there are significant features to the customization tools. Offices are advised to give some consideration to the desired outcomes before attempting to use these tools. In particular:
Why are Clinical Findings Information being stored within Capable 21C?
Who will enter the Clinical Findings data?
How and when will the data be retrieved?
Will the data be provided to patients/clients? Or is it purely for internal use?
What procedures will be followed to collect clinical findings information on any individual patient/client?
What supporting tools and documentation will be required by the office (eg forms, manuals or work instructions)?
In essence, the clinical findings system is broken down into several major areas of information. These cover a range of Subjective, Objective, Assessment and Planning tasks. When Capable 21C is shipped, it is supplied with the following 7 areas preconfigured:
Major (or chief) complaint.
Secondary Complaints (also known as In Depth Health Questionnaire).
X-Ray Analysis Findings
Recommendations for Care
Some of these areas can be used in a variety of ways. For example:
Examination Findings for a New Patient/Client
Progressive Examination Findings
Re-evaluation Examination Findings
Legal or Insurance Report Examination Findings
Some of the areas have distinct similarities. For example, the X-Ray Analysis, Diagnosis, Prognosis and Recommendations for Care all use standard sentences and paragraphs to assemble a report. Whilst some fine tuning of the language and detail is required at the time of data entry, essentially, they are a range of pre-defined paragraphs that the practitioner can mix-and-match to create a report.
Similarly, the Examination Findings and the In Depth Health Questionnaire have similarities in that they combine some kind of test or condition with some kind of finding or result. For example, a Minor’s Sign test may produce a positive or negative result. A patient/client with migraine headaches may experience them frequently, constantly or rarely.
To assist an office in collecting the necessary data, and to facilitate data entry, Capable 21C has the ability to produce a series of forms related to each of the information areas. There are also forms that facilitate the collection of data for progressive examinations. Whilst these forms are not essential to the use of the Clinical Findings tools, they make it significantly easier for offices to understand how the system works, and to capture and enter the data. These forms can only be printed on systems that have both Capable 21C and Microsoft Access (Version 97 or above) installed.
Each of the forms shows the information options available to the practitioner. It also includes a numerical code beside each of the choices. A practitioner can run down the form quite quickly and tick off the entries that are desired. For some of the entries, additional text may need to be entered (as with the example above of the frequency of migraines). When the time comes to enter the data into Capable 21C, it can be entered by keying the numerical code (and additional text that has been nominated by the practitioner or patient/client). This way, a large report can be assembled with only a handful of numerical codes.
In customizing the forms, a practitioner should consider:
Is there any particular need to alter the numerical codes provided by the system?
Is there any particular need to alter the wording of any of the options?
Is there any particular need to add or remove entries from the system?
Can the forms produced by Capable 21C be used without alteration? If not, would it be possible to use them with some alteration? If not, would it be simpler to alter the office’s existing forms so that the numerical codes are displayed.
Once a decision has been made to alter forms, use the procedure outlined below to do so:
To alter forms:
Go To Setup|Alter Forms.
Nominate the desired form for alteration.
Click the Edit button. The form alteration window will appear.
Right click on any text to alter the text, the numerical code or to delete the text.
Select the desired option from the fly out menu.
Once the form has been altered to suit the office’s needs, click the Close button. Click Yes to apply the changes.
Capable Software Pty Ltd recommends that an office print the existing forms, and discuss their usage with the office staff before making any changes. It may even be beneficial to trial the forms ‘as-is’ before altering them.
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