Documentation/User_Guide/07.html

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   6 <title>OpenEMR v3.0.1 Users Guide</title>
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  13 <h1>OpenEMR Users Guide (version 3.1.0)</h1>
  14 <h3>Table of Contents</h3>
  15 <ul>
  16 <li><a href="01.html">Getting Started</a></li>
  17 <ul><!-- InstanceBeginEditable name="TOC1" --><!-- InstanceEndEditable --></ul>
  18 <li><a href="02.html">Main Screen & Navigation</a></li>
  19 <ul><!-- InstanceBeginEditable name="TOC2" --><!-- InstanceEndEditable --></ul>
  20 <li><a href="03.html">Setting Up Your Clinic</a></li>
  21 <ul><!-- InstanceBeginEditable name="TOC3" --><!-- InstanceEndEditable --></ul>
  22 <li><a href="04.html">Adding a New Patient</a></li>
  23 <ul><!-- InstanceBeginEditable name="TOC4" --><!-- InstanceEndEditable --></ul>
  24 <li><a href="05.html">Using the Calendar</a></li>
  25 <ul><!-- InstanceBeginEditable name="TOC5" --><!-- InstanceEndEditable --></ul>
  26 <li><a href="06.html">New Encounters & Coding</a></li>
  27 <ul><!-- InstanceBeginEditable name="TOC6" --><!-- InstanceEndEditable --></ul>
  28 <li><a href="07.html">Issues & Immunizations</a></li>
  29 <ul><!-- InstanceBeginEditable name="TOC7" -->
  30 <li>Adding Issues</li>
  31 <li>Associating Issues with Encounters</li>
  32 <li>Immunizations</li>
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  34 <li><a href="08.html">Patient Notes & Transactions</a></li>
  35 <ul><!-- InstanceBeginEditable name="TOC8" --><!-- InstanceEndEditable --></ul>
  36 <li><a href="09.html">Basic Billing</a></li>
  37 <ul><!-- InstanceBeginEditable name="TOC9" --><!-- InstanceEndEditable --></ul>
  38 <li><a href="10.html">Accounting & Receivables</a></li>
  39 <ul><!-- InstanceBeginEditable name="TOC10" --><!-- InstanceEndEditable --></ul>
  40 <li><a href="11.html">Reporting</a></li>
  41 <ul><!-- InstanceBeginEditable name="TOC11" --><!-- InstanceEndEditable --></ul>
  42 <li><a href="index.html">Index</a></li>
  43 </ul>
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  51 <h2>Issues & Immunizations</h2>
  52 <h3>Adding Issues</h3>
  53 <p>An "issue" is a medical problem, allergy, medication, surgery or dental issue. These issues are related in that they can all be associated with multiple encounters. </p>
  54 <p>This is especially useful with medical problems, where the user may want to quickly determine which encounters treated a particular problem, or which problems were treated by a particular encounter. </p>
  55 <img src="Issues & Imunizations/01-issues_summary.png" />
  56 <p>From the patient's Summary page click 'Medical Problems (more)', or select 'Issues' from the navigation menu on the left ('Patient/Client – Medical Record – Issues') to display the Issues list.</p>
  57 <p>You can now see the prescription added earlier has been included in the Issues list as a Medication.  Click 'Add Issue' to add a new medical issue you want to kept track of for this patient.</p>
  58 <img src="Issues & Imunizations/02-issues-issues_list.png" />
  59 <p>This pops up the 'Add Issue' dialog box. </p>
  60 <p>The default issue type is set to 'Problem'.  For each issue type there is a list of commonly selected titles which are customizable for your clinic's specific needs.  If the desired title is not included, it can be typed into the text box below the list. </p>
  61 <p>Enter the appropriate beginning and end dates, and select the 'Occurrence' from the drop-down list provided.</p>
  62 <img src="Issues & Imunizations/03-issues-add_issue1.png" />
  63 <p>Clicking in the 'Diagnosis' field will present a search dialog for locating the correct ICD9 code for this issue.  Enter the appropriate search term and click 'Search' to bring up a list of possible ICD9 codes.  Selecting the desired code will close the search window and enter the selected code in the text field.</p>
  64 <img src="Issues & Imunizations/04-issues-add_issue-search.png" />
  65 <p>Complete the remainder of the form as necessary and click 'Save'. </p>
  66 <img src="Issues & Imunizations/05-issues-add_issue2.png" />
  67 <p>Additional issues are entered in the same manner; clicking 'Add Issue' and selecting the appropriate type, such as 'Allergy'.  Notice that the 'Add New Issue' dialog also uses the OpenEMR date selection tool described earlier. </p>
  68 <img src="Issues & Imunizations/06-issues-add_issue3.png" />
  69 <p>Once the new issues have been added successfully you should see an updated list of all the issues that have been entered for this patient.  You may click on an issue in the list at any time to edit it.</p>
  70 <img src="Issues & Imunizations/07-issues-issues_list2.png" />
  71 <h3>Associating Issues with Encounters</h3>
  72 <p>The far right column in the Issues list represents the number of encounters associated with a given issue.  Click on the '0' next to a newly added issue to bring up the 'Issues & Encounters' dialog.</p>
  73 <p>This dialog contains a list of all the issues and encounters associated with this patient.  It is used to set (and view) the relationships between issues and encounters.  Note that the issue that was just clicked on has been highlighted. </p>
  74 <img src="Issues & Imunizations/08-issues-associate_encounter.png" />
  75 <p>Select the appropriate encounter from the list on the right to highlight it.  Clicking 'Save' now links the selected issue to the selected encounter.</p>
  76 <img src="Issues & Imunizations/09-issues-associate_encounter2.png" />
  77 <p>Continue associating issues with encounters as necessary.  Refreshing the Issues list shows the current information for all issues.</p>
  78 <img src="Issues & Imunizations/10-issues-issues_list3.png" />
  79 <h3>Immunizations</h3>
  80 <p>Click 'Summary' on the left (under ('Patient/Client – Management') to return to the Patient Summary page.  Now click 'Immunizations (more)' to add an immunization for this patient.</p>
  81 <img src="Issues & Imunizations/11-issues_summary2.png" />
  82 <p>This page contains a form for entering information on the any immunizations the patient has received.</p>
  83 <p>Select the type of immunization from the drop-down list provided, and enter any data you may have, including the date of the shot, and the name of the provider who administered it. </p>
  84 <img src="Issues & Imunizations/12-issues-immunizations.png" />
  85 <p>Click 'Save Immunization'.  The newly added immunization now appears in the list at the bottom of the screen.</p>
  86 <img src="Issues & Imunizations/13-issues-immunizations2.png" />
  87 <p>Return to the Summary page via the navigation menu on the left.  Notice that the lower left portion of the patient summary now shows a brief list of all active issues, immunizations and prescriptions. </p>
  88 <img src="Issues & Imunizations/14-issues_summary3.png" /><br><br>
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