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OPUS
Medical Record Module
Quick
Views Of Patient Medical Data
Development
of the OPUS Medical Record module
began over two decades ago by medical professionals
for medical professionals. The physicians on the
original design team set the framework for a comprehensive
system to fit the diversities in medical environments,
specialties, and sub-specialties. Our physician
clients continue to be a part of the OPUS
System design and development team.
As
with all modules of the OPUS System,
the Medical Records module is
flexible in the collecting, recording, and retrieving
of patient medical information. It improves and
expands upon the capabilities of the traditional
medical record in terms of accessibility, timeliness
of retrieval, legibility, and organization. Your
practice may utilize the features of this module
as extensively as you would like. Screen displays
and printed output are tailored to your practice’s
needs and the type of medical care given. Medical
report formats are defined by your practice.
Pathway
to the CPR (Computerized Patient Record)
We
recommend a ten step process to gradually phase
in the medical record. These steps may be implemented
in time intervals suitable to your practice.
Step
1: Registration
Step 2: Encounter Entry
Step 3: Transcription
Step 4: Instructions
Step 5: Vital Signs
Step 6: Medication/Allergies
Step 7: Problem List
Step 8: Diagnostics
Step 9: Health Assessment
Step 10: Structured Data |
As
you complete each step, your staff will benefit
by having online access to the patient’s
medical history (no need to pull the paper chart)
for dictation, prescription, refills, laboratory
results, patient recalls, and faxing encounter
information to referring physicians.
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