HOWTO: Add New Patient

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Introduction

This guide will walk you through the process of creating a new patient record in LibreHealth EHR.

Creating a new patient is a straightforward process in its general steps, but the specific data entered will depend on your facility requirements.

The high-level summary is:


1. The new patient’s minimum required identifiers are entered

2. The patient’s record is created

3. Once the record exists, additional demographics and historical data can be added at a later time.


In this guide, we are going to show the steps to add all the demographic and historical data at once, including uploading scanned documents like an ID card or externally produced clinical information, such as lab reports.


Virginia Balseiro, LibreHealth EHR Documentation Intern Applicant, 15th October, 2018

Procedure

Adding a New Patient

1. Log in to your LibreHealth EHR account. In this example, we are logging in as an administrative user.


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2. Open the Patient/Client menu, and there select Add New/Search.


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3. Enter the patient’s information. The required values for a new patient are the red items: the name, sex, and date of birth. If your facility needs other defaults, they will appear in red text.


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4. The date of birth, and most other dates in the EHR system are entered by a calculator widget that works like this: you can scroll to the year that you want, advance to the month or pull it back, and of course select the date.


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5. Select the checkbox to open the next group. The next group is Contacts.


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6. Here you can add any contact information you have about the patient.


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7. The next group is Privacy. Here you can enter the patient’s privacy preferences. Many of the items in this and the following groups are HIPAA required data.


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8. The next group is Employer. Here you can enter the patient’s employer information.


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9. The next group is Social Statistics, which contains more HIPAA information.


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10. The next group is Insurance. These insurance drop-downs are populated by the list of insurance companies that the facility does business with, and those are entered during the facility set up. These text labels are red, and therefore required, but only if you indicated the patient has insurance. If there's no insurance, they will not trigger an alert for required data. However, if you put any information in any of the insurances, you need to fill out all the red fields for that policy. The system accepts primary insurance, secondary provider and tertiary insurance


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11. Once you are done filling in all the information, you can click Create New Patient at the bottom of the page.


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12. A search for duplicates will open. Check that there are no matches, and then you can click Confirm Create New Patient.


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13. This will take you to the newly created patient record. At this point, the only widget in the record that should contain any information is the demographics.


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Anytime you receive outside patient information, you can scan it into your PC and then upload it to the EHR, and put it in your patient record. We will now see how to do that from the patient summary screen.

Adding Information to the Patient Record

The links under the patient name have a few items relevant to this workflow:

  • Documents, where we can upload a patient’s documents such as an ID card.
  • History covers such things as family history and lifestyle information.
  • Issues opens the screen for the patient's medical history, such as allergies, surgeries, medication issues, etc.


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LibreHealth’s default access control permissions for the front desk user group do not normally permit them access to the History or the Issues screens. That is reserved for the clinicians and the providers.

If your house policy is different, a LibreHealth administrator can add the medical history permission to any user group.


Documents

1. In the patient summary screen, click on Documents.


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2. Select from the list of document types.


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3. This list of document categories can be adjusted by an administrator to the categories in your facility needs. Once you choose the document you wish to upload, a new screen will appear to the right.


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4. Click Choose Files to open a dialogue window where you can locate the file in your computer.


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5. The click Upload to effectively upload the file to the patient’s record. The “Download document template for this patient and visit” checkbox does not apply to Upload, but to the Fetch button.


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6. Once you have uploaded the patient’s document, you can check in the summary that they have been effectively added to the patient’s record. In this example, we uploaded an ID card. When we go to the summary, we see that the ID card has been uploaded.


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That is how a patient's demographics and external documents are incorporated into their record. Now let's look at the other items on the patient summary screen, where we'll be entering the remaining historical data.


History

1. Click on History link, and you see the tabs of the different types of historical information that can be collected here. Please note that the contents of all these History screens and tabs can be very easily customized by an administrator in the Layouts module, but this is what is present by default.


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2. To add information, click on Edit.


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3. Under General, there is a quick list of the conditions the patient may have now or have had in their in their background, with the tests that they have taken and a free-text area for notes.


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4. Under Family History, you enter health problems of the different family members with diagnosis codes if available.


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5. After entering a condition, click on the Diagnosis Code box and a dialogue will open. Enter a partial code indicator or free text, click Search, and you get the code for this condition.


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6. Select the condition from the results list and the code will be entered into the form.


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7. Relatives is the extended family. Simply enter which family member has which condition.


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8. Under Lifestyle you can enter information about the patient’s habits. For tobacco, for example, you enter what form (cigarettes, vaping, etc), the frequency, and the status of the lifestyle factor (if it’s current, if they've quit, etc), the cessation date, etc.


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9. The Other tab is a fairly generic screen, which is useful to customize for other purposes, for example to enter any lifestyle factor that is not mentioned elsewhere.


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10. Once you are done, click on Save.

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Issues

Accessing the issue screen

There are two ways of accessing the Issues of a patient record:

1. By clicking on their individual Edit buttons on the Summary page:


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2. By clicking on the Issues link under the patient’s name:


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This takes us to the Issues page, where we can add any of the issues listed.


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Adding a new issue


We will now review the procedure to add a new issue. In this example, we will add a new medical problem.


1. Click on add.


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2. The issue entry panel opens, some are pre-entered. You can select one of the pre-entered options, or you can manually type the problem title. If any active issue codes have been entered already, it shows up in the activation code.


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3. If you need a code for this particular problem, you click in Codes, and you type in a partial text, search, and select the code.


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4. Set the begin date with the regular calendar widget. If it's a current issue, leave the end date empty.


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5. There are a number of fields that you can fill out in this panel:

  • Occurrence severity: you can choose from Mild to Fatal.
  • “Referred by” is where you can enter any referring physician or practice.
  • Comments is a free-text field.
  • “Outcome” can be set to a status from Resolved to Pending. if it's not resolved don't select an outcome.
  • Destination is where you enter relevant information is the case that the patient has been sent to secondary care specialist, etc.


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6. After you fill out these fields, Click Save.


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Each issue’s entry panel has similar layout, the only difference is the pre-entered list of types of problems.

The rest of the issues can be handled in the same way. Regarding medications, if we list them as an issue, it means that the medication itself is a treatment issue, not that these are current medications. Medications are added in a different workflow.


7. If an issue has been resolved, go to the issue screen and open the issue.


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8. Select Outcome Resolved.


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9. Enter resolution date, and click Save.


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10. Return to the Summary screen to verify that the issues are displayed there.


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That is the complete workflow of how to create a new patient record, and enter their history.

Summary

In this guide, we reviewed the steps needed to add a new patient record, and update it by adding more information, such as documents, medical problems, and family information, at a later time.

We hope this guide has been helpful to you, and that you have a better understand of how to work with these features of LibreHealth EHR.

In the case you have any doubts, we recommend you visit the LibreHealth community in the LibreHealth Forums, where you can get in touch with the developers and other users who may be able to assist you.

If you have any questions or suggestions regarding this guide, you can get in touch with the author using the information in the “Contact the Author” section below.


NOTE: the contents of this documentation is the responsibility of the author.
If you have any questions please contact: Virginia Balseiro at virginiabalseiro@gmail.com