SigmaMD Clinician's Encounter Screen is a repository of organized and accessible patient information. Among its crucial sections, the Health Data part stands out for its comprehensive representation of a patient’s health profile. This section encapsulates a variety of health data resources. Here’s a detailed exposition of the Health Data section, its components, and how to interact with it:
Health Data Resources Overview
When you view the Health Data section, you’ll find the following resources:
- Vital Measurements
- Diagnostic reports
- Service requests
Each resource type displays a counter next to it, enumerating the number of records present.
Adding New Records
To add a new record to any of the six manually editable resources, namely Conditions, Allergies, Medications, Procedures, Immunizations, and Vital Measurements, click on the "Add record" button. While both clinicians and patients (via the SigmaMD patient mobile app) can add records, any record added by the clinician cannot be edited by the patient on the mobile app.
Editing and Deleting Records
Each record comes with a pencil icon for editing and a trash icon for deletion. Clicking the pencil icon enables you to amend the record, while clicking the trash icon will remove the record. These actions should be done with caution to maintain the accuracy and integrity of the patient's health data.
Adding Records to Clinical Notes
A right arrow icon adjacent to some records like Conditions, Allergies, and Vitals allows you to add these records to the clinical note swiftly.
The records in SigmaMD are coded to terminology codes as displayed in the add record form, adhering to the following coding standards:
- ICD-10 for Conditions
- RxNorm for Allergies and Medications
- CPT for Procedures
- CVX for Vaccines
Standardized terminology codes are important for interoperability and accurate record-keeping.
Each record exhibits a source, clarifying where the information originated. The sources could be a connected portal (e.g., Stanford Health), patient entered (via the SigmaMD patient mobile app), or clinician entered (in SigmaMD Clinician).
Imported and Generated Records
The records under Diagnostic reports, Service requests, Goals, Devices, and Encounters are either imported from connected patient portals or generated from lab orders and encounters within SigmaMD Clinician.
The Health Data section in SigmaMD Clinician is instrumental in housing a robust and detailed patient health profile, facilitating a well-informed and personalized care approach. By understanding and efficiently navigating this section, clinicians can significantly enhance their patient management and care delivery endeavors.
For any further assistance or queries, the SigmaMD support team is always at your service.