The patient chart documents all details and activities related to the patient. It is your source for inputting and finding information regarding each patient.
In this article you'll learn about:
Patient List
The Patients tab provides a summary list of all patients in your practice across all locations.
The list can be sorted by:
- Last name
- First name
- Middle name
- Date of birth
- Phone number
- Email.
To sort the list, use the grey arrows (ascending and descending order).
A red exclamation mark near the patient's email indicates that the patient has not confirmed their email address and thus cannot receive patient billing emails for security reasons, but they will still receive all appointment-related emails.
You can remind the patient to confirm their email by resending a reminder email. In order to do this, click the three dots associated with the patient and select Resend Email Confirmation.
Patient Search
To search for a patient, use the search field where available. Search will render results based on first or last name, phone number, or email address.
Adding a New Patient
New patients can be added:
- from the Patients tab
- when creating an appointment.
Select the +Add New Patient button.
Input the patient details then click Add Patient. At a minimum, you need to input their first name, last name, and date of birth to create a patient account.
The patient account will be added to the list.
Patient Chart
To access a patient's chart, click on the patient's last name in the patient list. Patient chart is not currently accessible from the appointment.
Note: Patient chart sections are customized during your practice onboarding and thus may differ for your practice.
Patient Details
Patient Details include contact information for your patient: first name, last name, middle name, SSN, email address, phone number, state, city, street and zip code.
Patient Demographics
Patient Demographics include additional information about the patient: general information, date of birth, gender, sexual orientation, gender identity, preferred language, race, and ethnicity.
To edit patient demographics, use the Edit button.
Insurance
You can add patient insurance with the +Add Insurance button which opens in a new tab within the integrated RCM module for claims management. Adding insurance details to the RCM will automatically display the insurance in the patient's chart.
Past Medical History
In Past Medical History you can manage details concerning the patient's previous medical information.
To edit past medical history, use the Edit button.
Fill in the known medical conditions and click Save when you are done.
All the changes will immediately be visible.
Social History
Social History captures information about the patient's social life: relationship, employment, and religious affiliation. To get started, click +Add Social History.
Choose options from the drop-down list provided and add additional information concerning any patient abuse if relevant. Click Save when you are done.
You can further edit the data or completely remove the data if needed.
Family History
Family History captures information concerning the patient's family. To get started, click +Add Family Member.
Add the information and save your changes when you are done.
The family member will be added to the list and given an ID number for reference purposes.
Allergies
Allergy information will either be populated from Rcopia if you have integrated eRx or can be manually inputted if you do not have integrated eRx.
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Add Allergy Manually
Without integrated eRx via Rcopia, you will be able to add allergies manually by going to the Allergies section in patient details.
Edit Allergen Items
1. To edit an allergen item, simply choose the desired patient record and click on the Allergies section.
2. To make changes, click on the Edit button.
3. Enter the new information and hit Save.
Change Allergy Status
In order to change the status of an allergy, click on More Actions and Mark as Inactive.
The status will change to Inactive.
Note: you can also make an allergy Active.
Remove Allergy from the List
1. If you need to remove any record from Allergies, click Remove.
2. Confirm your action by clicking the Yes, delete button.
The allergy record will disappear from the list.
Medications
Information about Medications also depends on whether you activate eRx or not. If you do not activate eRx you will be able to add Medications manually from the Medications section.
You are able to easily find the desired medication when sorting by column using the arrows provided.
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Encounters
Encounters are documented details about the patient's visit to the practice. From the Encounter section in a patient's chart you can see the list of all encounters for the patient.
Problem List
The information about the Problem list that you see in Remedly depends on whether you activate eRx or not.
If you do not activate eRx you will be able to add Problem list information manually.
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Goals
Here you can document the goals that a patient wants to achieve with the help of your services.
Click Add Goal.
Add goal details, its priority and a desired start date. After that save the information.
By clicking the ID of the Goal you will be able to see its details.
Practitioners Notes
Practitioner's Notes is a place where a practitioner can leave any thoughts, ideas, and any other details about the patient.
Practitioner's Notes can be seen only by creator of notes. They stored separately from patients records.
Click Add Practitioner's Note.
Add the note and click Save.
For security purposes only the subject is visible in the notes list.
The details can be seen by clicking on the subject.
Use the blue arrow to get back to the Practitioner's notes list.
The note can be removed If needed.
Administrative Notes
To create an administrative note:
1) Open the patient chart of the desired patient
2) On the left menu find Administrative Notes
3) Click on Add Administrative Note
4) Fill in the required fields and click Save
How to Edit an Administrative Note
To edit administrative notes:
1) Inside the patient chart, open Administrative Notes
2) Open the note you want to edit
3) Click Edit
How to Delete an Administrative Note
To delete an administrative note:
1) Inside the patient chart, open Administrative Notes
2) Click Remove