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.

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.

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

Selecting an existing Draft Report for Completion

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

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

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.

4. Select Add Template(s)

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.

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

Visit Number

• If there is an open Visit for the patient the Visit Number (and detail) will be displayed - see example below.
• If there is no open Visit you should select one from the drop-down. ALWAYS associate the proper Visit in the drop-down

Note: If a Visit is NOT associated you will NOT be able to Send the report to the owner, rDVM, etc.  Email medrec@vetmed.illinois.edu for assistance with exams lacking the Visit number. 

Example: Selection box with an Open Visit        

Example: Selection box without an open Visit

4. Select Exam Type and select Submit (It is VERY important that you associate a Visit or you will not be able to Send the report.)

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

6. Select Add Template(s)

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.

Note:

• Visit reports are auto finalized 7 days after last being edited.

 SANDI - Send Reports to Clients, rDVM, etc.