Help SiteClinic Users Medical RecordsMedical Records - Overview

Medical Records - Overview

All medical record entries occur with in a visit record.  This ensures that medical records are classified correctly and are provided as much structure as possible.       Medical records can be viewed with in individual visits, "patient hx widget" or at the patient record.

All entries are made with in a medical record note (MRN).    A MRN can be created by direct typing, cut/paste from another source, speech recognition dictation or by using medical record templates.

MRNS have 3 main categories and can have several sub categories.  The MRN type and catagorizaion can be customized with in your system.  The purpose of the structure is two fold, it allows easy entry and retrieval of relevant medical information and offers functional control points such as user privileges or what information is sent to a client or RDVM

 Below is a "typical" MRN structure

  • Medical Record
    • History
    • Physical Exam
    • Assessment
    • Diagnosis 
    • Therapy/Progress Notes
    • Medical Imaging
    • Discharge Instructions
      • Discharge Instructions
      • Client Follow up Instructions
      • Client Education
    • Reports
      • sx report
      • anesthesia report
      • procedure report
  • Communication
    • Client Call
    • RDVM Call
    • Client Letter
    • RDVM Letter
  • Internal Note
    • Internal Staff note
    • Intern Record Review
    • Accounting Note