Entering the Medical Report Details (Palliative)

Introduction

The medical report page allows doctors or Advanced Practice Nurse (APN) (only) to enter the details pertaining to the patient's medical report or diagnosis.

Prerequisites

To enter the medical report details:

You must log in as a doctor or APN.
You must have a hospital case number associated with the patient's case.

Entering the Medical Report Details

Note

The Retrieve Medical Info from eHIDS button is enabled only if you provide the patient case number. The Retrieve Medical Info from eHIDS button allows you to retrieve the information pertaining to the medical report from the hospitals and auto-populates the medical report page. However, you can modify a medical report if needed.

For more information on the fields that are retrieved, see eHIDS Information.

Proceed as follows:

On the Medical Rpt tab, in the *Primary Diagnosis Description textarea, type your primary diagnosis.

In the Remark field, type your remarks.

To add the primary diagnosis, click Add.
The primary diagnosis is added and displayed under the Primary Diagnosis Description table.

		Note
		Under Action, you have the option to delete or modify the primary diagnosis added.

In the *Secondary Diagnosis Description textarea, type your secondary diagnosis and repeat from step 2 to step 3.
You can add multiple secondary diagnosis description.

In the Does the patient have any of the following? section, select the diseases or problems the patient is diagnosed with as follows:

Field Name	Description
NA	Not Applicable.
Infectious Disease	The patient is diagnosed with infectious diseases such as HIV/AIDS. You can also select the precautions required, such as, Standard, Contact and Isolation and so on.
Malignant Disease	If the patient is diagnosed with malignant disease, you can specify it.
Dementia / Psychiatric Problems	The patient is diagnosed with Dementia or psychiatric problems. You can select the Type of Dementia/Psychiatric Disorder as follows: Multi-Infarct/Vascular Alzheimer's Disease Others Under Dementia/Psychiatric Disorder Followed Up, select one of the following: No -- if not followed up by a doctor. Yes -- if followed up by a doctor. This option allows you to further provide information pertaining to doctor's follow up. Under Cognitive & Behavioural Symptoms, select and provide details as follows: Paranoid and Delusional Ideation Hallucinations Day/Night Disturbance Anxieties & Phobia Does not exhibit this behaviour Activity Disturbance: >Wandering >Purposeless Activity >Inappropriate Activity >Does not exhibit this behaviour Aggressiveness: >Verbal Outburst >Physical threats &/or violence >Agitation >Does not exhibit this behaviour Affective Disturbance: >Tearfulness >Depressed Mood/Other >Does not exhibit this behaviour You can provide any additional comments in the textarea provided.

In the Brief Clinical History on Treatment of current /past medical and surgical problems section, you can enter the patient details under the following categories:

a) Present main complaints/Past medical and any surgical procedures and history (if any)/Summary of Management Plan [(to date) include special treatment e.g chemotherapy/DXT:

Field/section Name

Description

History

Past medical complaints or medical history of the patient.

Procedures:

    Procedure Description
    Remarks
    Date

Details pertaining to the surgical procedure (if any) performed on the patient in the past.

Add

Allows you to add the patient's medical history record.

b) Investigations, significant laboratory results/ radiology (e.g MRI, CT Scan)/Scan findings:

		Note
		If the any of the fields/sections pertaining to the laboratory results are not applicable, select NA (Not Applicable) and you are not required to enter any further details.

Section/Field Name

Description

Laboratory Results

Patient's lab results.

Latest Chest X-Ray Result:

Date when the chest X-Ray was taken.
Enter the following details pertaining to the chest X-Ray results:

Not Applicable -- You are not required to enter any details.
Date Taken (dd/mm/yyyy) -- Date when the chest X-ray is performed.
No Pulmonary lesions suggestive of active infection
Abnormal

Others

You can enter any additional remarks in the Others textarea (Investigations, significant laboratory results/radiology (e.g MRI, CT Scan)/Scan findings).

c) Drug Allergy History
Select one of the following:

Yes--If the patient has any drug allergy.
No--If the patient does not have any drug allergy.

d) Current Medication: Route/Name of Drug/Dose/Frequency
Enter the current medication details as described in the following table:

Section/Field Name	Description
Medication Name	Name of the medication given to the patient.
Dosage Regimen	Regulated course of medication.
Instructions	Instructions on giving medications.
Route	The method by which the medication is administered, for example, topical, intravenous, or oral.
Add	Allows you to add the patient's medical history record.

e) Patient Requires Rehabilitation
Select one of the following:

Yes -- if the patient requires rehabilitation
Trial Rehab Only -- if the patient is temporarily put for rehabilitation.
No -- if the patient does not require rehabilitation
NA -- Not Applicable

f) Weight Bearing Status

In the Weight Bearing Status list, select the patient's weight bearing status accordingly.

g) Other Remarks
You can add any other remarks or information on the patient's medical report.

In the Additional Information for Hospice Referral section, enter the details as described in the table:

Section/Field Name	Description
Histopathological Diagnosis	Patient's histopathological diagnosis available, select one of the following: Yes No NA
Sites of Metastases	Date of histopathological diagnosis.
Date of Diagnosis	Date of histopathological diagnosis.
Prognosis	Life expectancy of the patient.
Present Condition	Present condition of the patient.
Add	Allows you to add the patient's medical history record.

After completing the medical report, in the Completed By section, you can update the name, designation, telephone, email and date, accordingly.

		Note
		By default, the information of the user logged into IRMS is populated. The information (name, telephone number and so on) is based on the details available in the user’s profile.

When the medical report is ready, you can do one of the following:

Save -- to save the medical report as draft.
You may want to use the save option, if the page is partially populated or you do not want to submit it immediately.
Ready -- to save and mark the draft as ready to submit (indicated by flag in orange).

		Note
		The mandatory fields that are not entered properly are indicated with asterisks (**). A message is displayed on the top of the page to enter the required fields. You cannot submit the page without completing the mandatory fields. Once the page is submitted (indicated by flag in green), you cannot modify the details.

Entering the Medical Reports Details (Palliative)

Introduction

Prerequisites

Entering the Medical Report Details