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How to build a Case Sheet

The EMR module in Clinicea is built on a revolutionary piece of technology that can replicate paper. To design your customized EMR layouts, create Case Sheets.

For Example, Let us assume you want to create a Case Sheet for a Patient’s first consultation with you. You can call the Case Sheet “Consultation” and add the clinical sections you need e.g. Chief Complaints, Vitals, Medical History, Investigations, Treatment, Assessment, and Recall.

Let us have a look at how to build a Case Sheet:


1.
Select a Patient and open up the Patient Chart | Now click on the Case Sheet Icon.

 

2. A Case Sheet window will open | click on +Add New.

 

3. A Case Sheet Details window will open | Enter Case Sheet Name, For example, Consultation | you can check on Set as Default if you want to use this Case Sheet to be used each time you open up any of the Patients.

Now comes the exciting bit, you can start creating your Case Sheet.

Goto Set Layout, and Check On all the clinical sections you want to include in your Case Sheet. For example, Chief Complaints, Vitals, Medical History, Investigations, Treatment, Assessment, and Recall. 

You can also rename each clinical section, by typing in a Display Name. For example, let us rename Investigations to Lab and Radiology.

You can position each clinical section in the order you want by first selecting the section, Ex: Click on Treatment, it gets highlighted in green

Then simply click on the top arrow icon to move the section up. Keep clicking the up icon to move the section further up the page.

To see your changes click on the SAVE AND CONTINUE button at the bottom of the page.

 

4. OPTIONAL: You can also add a custom Print Template to your Case Sheet by selecting one from the drop-down menu. It is not mandatory to do this as each Case Sheet by default uses a Prescription Template that has been set up in each Clinicea account.

If before you can start the visit you need to take the Patient’s Consent, set the consent form to be used under Patient Consent. Ex: Patient has come to you for a Procedure.

Default Image for Male Patients: You can have a default image appearing from your Image library and link it to the Case Sheet. This is useful if you like to annotate or draw on images as part of your visit.

Default Image for Female Patients: Same as above, except that you can have a different image for female patients.

Click on SAVE AND CONTINUE and continue editing.

 

5. Your Case Sheet is now ready with all the selected Clinical Sections in place. Scroll lower to view them all.

 

6. You can now start adding data to the layout you have created. This can be done by clicking on the + button against a clinical section and searching from a pre-defined list on your right in green.
For Example: Let us select and add the Clinical Group “Relevant Past Medications” to Medical History.

You can also add new Clinical Groups, simply by typing in whatever you need in the search box and hitting enter. Clinicea will prompt you to confirm if you want to add a new group, say OK to it and that’s it, a new group had been added.

You can add and create as many Clinical Groups as you like. Multiple Clinical Groups can be added to each Clinical Section. (For more info, please have a look at How to create Clinical Groups using Tools).

 

7. Done! Your Consultation Case Sheet is now ready for use and has been made as one of your Favorite Case Sheets. There are 3 icons beside the Case Sheet name:

a. Apply:- This icon allows you to apply a case sheet that you need to work on.

b. Star:- Click on this option if you want to set a case sheet as favorite. When set, the icon will turn yellow. Click on the same icon to remove from the list of favorite Case Sheet.

c. Three vertical Dots:- Click on this icon to reveal a drop-down. From that drop-down, you can set the default case-sheet by default or edit the case sheet or delete the case sheet as and when required.