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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