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Layout of Medical Records

Dear SFS team,
Wondering if there are any plans to make the reports "flexible" in how the data is presented. My staff and I feel that the current layout of the pdf medical record data is very hard to read, as the dates and times are repeated over and over again.

In order to explain what I mean, currently the data in the report is laid out in this order:
[DATE] [TIME of ENTRY]: {PARAMETER}- [DAY+TIME ON CHART] - [USER DATA]
eg 05-Aug-14 14:39: Pulse - day 2 at 14:00 - 120

I find this layout confusing, especially as the "day 2 at 14:00" text is jammed in between the parameter "pulse" and the actual recorded figure "120"

I imagine that grammatically it makes sense if you read it out "The pulse on day 2 at 2pm was 120" but when I scan medical records, I just want to see tight packets of information, not dates and times repeated over and over again.

My suggestion for records would be to have the "Date" listed once, like it's a title for each day of obs. Then each scheduled "hour" of chart obs also listed once, not in the middle of parameter data - like a subtitle to define the group of obs.
Then each line of data just lists actual time of entry, parameter type, and data.

eg
[DATE]
[DAY+TIME ON CHART]
[TIME of ENTRY] {PARAMETER} [USER DATA]
[TIME of ENTRY] {PARAMETER} [USER DATA]
[TIME of ENTRY] {PARAMETER} [USER DATA]
[DAY+TIME ON CHART]
[TIME of ENTRY] {PARAMETER} [USER DATA]
[TIME of ENTRY] {PARAMETER} [USER DATA]
etc etc

actual case example:

04-Aug-14
Day 1 9:00
09:45 Resp. rate 76
Day 1 at 10:00
10:14 Attitude sitting up, looking around, more settled
10:14 Resp. rate 60
10:16 MM pale pink
10:28 Resp. rate 72
10:34 Chem10 KK
10:37 Radiograph BH
10:38 Urination +++
Day 1 at 11:00
11:05 Resp. rate 70
11:21 Frusemide 2.00 mg/kg IV 0.15ml
11:22 Client Communication KS has spoken to O

Note: I would also remove the extra dashes (-) and colons (:) is they clutter up the confuse the data when you are already using a colon in time stamps and sometimes dashes as data (meaning "nil").

eg 04-Aug-14 13:28: Urination - day 1 at 13:00 - -
doesn't really look like significant data has been entered at all, because of the preceding dash (13:00 --)

Once again I would like to see it something like this:
04-Aug-14
Day 1 at 13:00
13:28 Urination -

or perhaps replace the dash with "nil" as option for urination? eg options:
+++
++
+
Nil


Thanks for the consideration of these ideas,
Belinda
  • Belinda Haebich
  • Nov 11 2017
  • Open For Voting
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