SANDI - Medical Record Documentation (Visit Report, Image Uploads, SOAP Notes, etc.)

When a patient is registered in SANDI, a report titled “Visit Report” will automatically be created. A visit report should be created for all patient visits including suture removal, bandage changes, and visits where the patient dies. The only exceptions is lab work only (where the patient is not seen), and outpatient imaging. The patient visit report is printed for the owner at the time of discharge and is sent to the rDVM. Typically a Visit Report is started by a student and then an Intern or Resident will finish the report. Finally a faculty or Resident will verify the report.

Examination Medical Record Documentation Overview

1. Bring up the proper Client/Patient in the Patient’s Dashboard and select the arrow next to Exams/Forms.

SANDI-ExamsFormsForSend.jpg

2. The Exams/Forms screen will display all patient history. 

  • Sort: You can be sort by any column (ascending/descending) by simply clicking the column heading arrows.
  • Key Word Search: You can search by key word by typing in your search word in the search boxes just below the column heading.
  • Finalized entries have a Status of Finalized, and display in red.
  • Retracted items display in red and the font is struck through.

SANDI-ExamsFormsSendActions.jpg

  • View - Select the eyball icon viewblkto Send a Report
  • Send - Select the airplane icon sendto Send a Report
  • Edit Report Text - Select the paper/pencil icon  edit to edit draft reports
  • Delete - Select the retract icon delicon to retract a report.
  • Retract Exam - Select the retract icon retract to retract a report.

Selecting an existing Draft Report for Completion

1. Select Exams & Forms from the Patient Dashboard by selecting the arrow.

forms

2. Select the Edit button next to the proper visit. (Pencil Icon edit)

sel temp

3. At Template Selection expand your service and select all the templates you would like to include on your report. Those selected will appear in the right hand column.

serv temp

4. Select Add Template(s)

temp sel

5. You many now begin completing your template. 

Notes:

  • Please note the new time out feature list at the top left of the page along with an auto save time in the right corner.

6. Once your report is complete you may:

  • Submit - which simply saves the template
  • Verify - which will finalize the report. (Your PIN will be required)
  • Verify and Review for Send - This will bring up a print preview of the report and allow you to select recipients, other reports, etc. to send. (Your PIN will be required)
  • Draft Report View - Will display the report in draft.
  • Final Report View - Will require a PIN and finalize if still in draft/unverified.

Adding a Report

1. Select Exams & Forms from the Patient Dashboard by selecting the arrow.

Exams&FormsBox

2. Select Add (Blue button in upper left corner of the Exams/Forms box.)

3. Select the exam for which you are adding the report

4. Select Visit Report and select Submit

5. At Template Selection expand your service and select all the templates you would like to include on your report.

serv temp

6. Select Add Template(s)

temp sel

7. You many now begin completing your template. 

Notes:

  • Time out is listed along with an auto save time at the top of the page.  
  • You can select Templates and add additional ones to your existing report.

8. Once your report is complete you may:

  • Submit - which simply saves the template
  • Verify - which will finalize the report. (Your PIN will be required)
  • Verify and review for Send - This will bring up a print preview of the report and allow you to select recipients, other reports, etc. to send. (Your PIN will be required)
  • Draft Report View 
  • Final Report View - Will require a PIN and finalize if still in draft/unverified.

 SANDI - Send Reports to Clients, rDVM, etc. 




Keywords:send, email, phone, call, rdvm, em, fax, email, in-person, in person communications   Doc ID:110684
Owner:Tina O.Group:University of Illinois College of Veterinary Medicine
Created:2021-05-06 11:12 CDTUpdated:2022-01-24 16:58 CDT
Sites:University of Illinois College of Veterinary Medicine
CleanURL:https://answers.uillinois.edu/sandi-communications
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