LibreHealth EHR Add New Patient

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LibreHealth EHR Add New Patient

Introduction

This documentation provides a guide to using LibreHealth EHR to add a new patient. Users will learn how to add patient information with demographics and historical data at once, upload scanned documents or externally produced clinical information such as lab reports, add medical issues to the ones previously recorded, and mark an issue as resolved after a solution has been provided. The attached images are for easy navigation and the red arrows are pointers to make the app as easy to use as possible.

Ruth Obe, Libre Documentation Intern, 29 Mar 2018

Procedures

To Create a New Patient

  1. Login as a front desk staff on LibreHealth welcome page by entering the Username and Password and click Login button below the Language field as pointed by the arrow. You can choose to change the language preference from the language drop-down.
    Anp-01.png
  2. Go to the Patient/Client menu, which is the fourth item on the bar at the top of the page and select Add New/Search Item from the drop-down.
    Anp-02.png
  3. In the Face Sheet group on the right of the screen, add patient’s necessary information.
    • Note: The required information is in red. Add other information that can be input if provided.
      Anp-03.png
  4. Open the next group below the face sheet window and check the Contacts group to enter health provider details.
    Anp-04.png
  5. Open Privacy, Employer, Social Statistics groups below contact window to enter all necessary information.
    Anp-05.png
  6. Go to Insurance group. If the patient indicates that he/she has insurance, fill out all information for primary, secondary, and/or tertiary insurance providers. All labels in red must be entered for any insurance. If the patient did not indicate he/she has insurance, do not enter anything.
    Anp-06.png
  7. Click Confirm Create New Patient (in oval below) as pointed by the arrow. This opens a window to check for a duplicate that looks like the image below.
    Anp-07.png
  8. If no duplicates are found, click Create New Patient below the screen as pointed to by the arrow.
    Anp-08.png

You just successfully created a new patient record.

To Upload Future Patient Information to EHR

  1. In the patient summary screen, click on Documents below patient’s name as the arrow shows.
    Anp-09.png
  2. Select from the list of document types. The document uploads all work in the same way.
    Anp-10.png
  3. For example, to upload patient’s ID, click on the Choose Files to select Patient ID.
    Anp-11.png
  4. Select Browse in the dialogue box that appears.
  5. Locate patient’s corresponding picture.
    Anp-12.png
  6. Click the Upload button at the bottom of the Optional Destination Name.
    Anp-13.png
    • Note: the message, Download document template for this patient and visit, applies to the Fetch button not the Upload button.
  7. Click on the patient name, in this case, Patrick Boson on the upper left corner below the menu as shown by the arrow to return to the summary and view the ID.
    • Note: Libre access control permission for the front desk user group do not normally permit them access to the history or issues screen. That is reserved for clinicians and providers. If your health policy is different, a Libre administrator can add the medical history permission to any user group.

To Add Historical Information

  1. Click on History link below patient’s name as shown by the arrow.
    Anp-15.png
  2. Tabs of different types of historical information that can be collected is displayed.
    • Note: contents of all history screen tabs can be customized by an administrator in the layout module.
      Anp-16.png
  3. Go to each tab at a time.
    • Note: To add information, click on Edit beside patient’s name.
  4. Under Family History, enter problems each family member may have with diagnosis code if available.
    Anp-17.png
  5. To find Diagnosis Code, click on the diagnosis code entry box.
  6. In the window that appears, enter a partial indicator or free text in the Search for area.
  7. Click Search to get the code.
    Anp-18.png
  8. Under Relatives tab, enter members of the extended family who has which condition.
    Anp-19.png
  9. Under Lifestyle, enter what form of diseases.
  10. In Other section, you can customize for any other purposes that are not mentioned in the previous sections.
    Anp-20.png
  11. Click on Save (oval button below the Patient History/Lifestyle).
    Anp-21.png
  12. Click on the patient name, in this case, ‘Patrick Boson’ on the upper left corner below the menu to go back to the summary screen.

To Enter a Medical Problem

  1. From the issues screen, go to Medical Problems in the patient’s summary screen and click on Edit (oval button beside ‘Medical Problems’).
    Anp-23.png
  2. Click on Add (in the oval beside Medical Problems) as pointed by the arrow to open the issue entry panel.
    Anp-24.png
  3. Enter medical problem from the list or manually type the problem title in the Title box as shown below.
    Anp-25.png
  4. If issue code is previously entered, it shows in the Active Issue Code panel otherwise you can enter the code in the coding panel.
  5. Enter Begin date.
  6. Enter End date. If a problem is a current issue, leave end date empty.
  7. Set Occurrence, Severity, and Reaction.
  8. Enter Reference if any, add Comments, Outcomes if an issue has been resolved otherwise, do not select Outcome, and ‘Destination’ if the patient has been sent to a secondary care specialist.
    Anp-png.26
  9. Click Save at the bottom as pointed to by the arrow.
    Anp-27.png
    • Note: Each issue entry panel has similar layout except that the pre-entered list of error varies on different types of problems.

To Resolve an Issue

  1. Go to the Issues screen below patient’s name as pointed by the arrow to open Issues.
    Anp-28.png
  2. On Outcome towards the end of the screen, select Resolved from the drop-down.
    Anp-29.png
  3. Enter End Date and Destination.
  4. Click Save (oval button below ‘Destination’ entry box).
    Anp-30.png
    • Note: Resolved issue appears in black.
    • Return to summary screen to see issues that are displayed.

Conclusion

This documentation has provided steps for easy workflow when using LibreHealth EHR application to promote efficiency in accomplishing clinical tasks. Following through would create a new user entry with additional details and allow users to enter historical and medical information of patient for a successful workflow. The visual aids are guides to finding where terminologies are located on the screen when using the application.

Contact Author

  • Ruth Obe - ruthobey@gmail.com