Electronic Medical Record
Electronic Medical Record (EMR) is the central repository for holding the entire medical records of the patient. It stores data in an organized and structured manner so that a clinician or any other clinical user is able to easily access clinical data based on his role, security rights and on need basis. EMR generated by RCare Magnum captures almost all the vital information needed by the doctor during the course of Patient Episode.
Salient Features
- Following information can be updated from the Physician's desk
- Chief Patient Compliant
- History of Presenting Illness
- Past Medical History of the Patient
- Drug History of the Patient
- Allergies
- Review of Systems
- Family History
- Social History
- General Physical Examination of the patient
- Diagnosis
- SOAP (at the time of follow up visit)
- Progress Notes for the patient
- Prognosis Notes for the patient
- Dietary details of the patient
- Referral Details
- Transfusion reactions on the patient
- 'Pharmacy Orders' and 'clinical orders' placed by doctor from order communication
- All Laboratory related details (investigation results, readings, lab technician comments)
- All radiology related details (radiologist reports) gets updated into the EMR
- Allow to update the 'ADT Details' of the patient if the patient is an Inpatient
- Allow to update nursing activity related data such as vital signs of the patient, nursing care plan, fluid balance charts, nursing protocols, drug chart, drug infusion details, vaccination details, blood bank details
- Updates surgical notes and anesthetic notes into the EMR
- Allow to update discharge details on discharge of the patient