The Patient tree

The timeline is a list of the Patient or Client's significant clinical events.

Some examples of significant clinical events include:

• Document created.
• Document.
• Reaction added.

Click on the event in the timeline to view further information about it.

A list of all the consults the patient has attended at the practice in chronological order. When the clinical record is opened in view-only mode, a Record update can be started from here.

Click on a consult to view more information about it. You will have the option to append notes to the consult, or print the consultation notes.

Add diagnoses or procedures that the Patient or Client has had in the past. Bp Omni uses SNOMED codes for diagnoses and procedures.

1. Click + Add Medical Hx. The Add medical history screen will appear.



2. Begin typing the name of the Diagnosis or Procedure. A list will appear to select the diagnosis or procedure from.
3. Indicate of the diagnosis or procedure is the Reason for consult, and if the diagnosis or procedure is Clinically significant.
4. Indicate the Certainty of the diagnosis or procedure.
5. enter the date When the diagnosis or procedure occurred.
6. Indicate whether you want the diagnosis or procedure to be Active or Inactive.
7. Add any further Details required and click Save.

Alternately, click No significant history to record that the patient has had no significant diagnoses or procedures in the past.

The correspondence section lists all incoming and outgoing correspondence relating to the patient.

Click the Title of the correspondence to view it.

To create a new letter, click Create document. See Using the Document Writer for more information.

To upload a new file:

1. Click + Upload new file. The Upload file screen will appear.



2. Drag and drop the file you wish to upload onto the upload file screen, or browse to the file and click Open.
   
3. Select the provider that the correspondence is addressed To.
4. Select who the correspondence is From.
5. Indicate whether the correspondence is Incoming or Outgoing.
6. Select the Correspondence Type.
7. Click Save.

The investigations section contains a list of all investigations returned to the practice regarding the patient.

Click the + (plus) icon next to Reports to upload an investigation.

See Manage Results in the Inbox or Clinical Record

Clinical images can be uploaded to file or store clinical photographs in the system. When uploading a clinical image, you are presented with the following options:

• Make the image confidential
• Declare whether or not the image is acceptable
• Move the image to correspondence or investigations
• Print the image
• Create a task outcome for the image.

A number of clinical tools are available in Bp Omni to assist with diagnosing and measuring severity of various patient conditions.

The clinical tools available in Bp Omni are as follows:

• Disability of the Arm, Shoulder and Hand Score (DASH11)
• Depression, Anxiety Stress Scale (DASS-21)
• Global Rating of Change Scale (GRCS)
• K10
• Numeric pain rating scale (NPRS)
• Örebro Musculoskeletal Pain Screen Questionnaire
• Patient Specific Function Scale (PSFS)
• RAND-36
• Oswestry Disability Index (ODI)
• Edinburgh Postnatal Depression Scale (EPDS)

See Clinical Tools for more information.

This section contains fillable history and examination forms that will help assess the client's history and record data such as pulse, blood pressure, temperature, reflexes and body parameters.

History

• Use Presenting complaint to capture the details of the issue that the patient presents with. Outline the problem details such as mechanism of injury, history of the injured area, and nature of the injury as shown in the below-right picture. Structured notes will be generated in Today's notes form this information.
• Use Clinical flags to record red and yellow flags that are relevant for the patient at the time, or select No abnormalities detected. Structured notes will be generated from these selections.
• Use the Systems review form to record general patient medical history. Values entered for Systems review will display under the Subjective header of Today's notes.
• Use the Medications & supplements form to record current patient medications and supplements.

Examinations

Use the General examination to record pulse, blood pressure, respiratory rate and body parameters.

Use the Body examination section to provide structured data for range of motion (ROM) and a series of other tests, with automatic generation of structured notes.

Most selected diagrams other then 'Body' and 'Abdomen' will contain the following tests:

• Range of motion (ROM)
• Spine contains Active and Passive for each area.
• All other areas contain Active and Passive movement options for both left and right.
• Special tests
• Strength tests
• Comments

'Abdomen' and 'Body' will contain comments only, allowing you to record Observation, light and deep Palpation, and Auscultation.

Structured notes are generated for each body examination recorded.

D/M/R

Dermatomes

These tests cover both light touch and pinprick tests, and are used to test areas of suspected impaired sensation. These tests are broken down into four categories:

• Trigeminal
• Cervical
• Thoracic
• Lumbosacral

For each section in Dermatomes, you can select one or more nerves that have been tested and record the result in bulk. Select the side of the nerve, or select the entire nerve to assume both sides.

There are four estimation options, this allows you to record nerves that have the same result and estimation at the same time. If a nerve or the side of a nerve has a different estimation, record this as a separate entry. The separate entry will only allow you to select a nerve or side of a nerve that has not already been estimated.

The same process can be done for Cervical, Thoracic, and Lumbosacral.

Myotomes

Select the Myotomes that have been tested from the dropdown and use the slider or the number picker to select the result out of five.

Reflexes

Select the reflexes that have been tested and record the result using the slider or the number picker out of five.

Once the examination is saved, notes are generated based on what has been recorded in D/M/R.

Cranial Nerves examination

The Cranial nerves section provides the ability to record results of testing the cranial nerves. Relevant tests are available for each nerve or group of nerves.

Structured notes will then be generated based on completion of the form.

Use the Treatment & management section of the Patient tree to record treatment information and create a management plan for a patient.

The management workflow allows you to create a plan for the patient, outlining the management of their condition. The condition selected from this form will the linked to the consult upon saving the form.

Use the family and social history section to record information about the patient.

The family and social history section contains eight categories.