Medical Record
TIP
This isn't a regular tab, but a separate page. You reach it via the More button in the record's tab bar.
This page combines two things: care plans, and a list of medication.
Care Plans
Each care plan is shown as a collapsible block. Click the title to expand or collapse it. Click the plus icon at the top to create a new care plan.
Creating or Editing a Care Plan
- Title and description.
- Status: draft, active, on hold, completed, revoked, entered in error, or unknown. The status also gets a color in the overview.
- Goals: type a goal and press Enter to add it. You can add several goals, and remove them again via the cross on each label.
- Addressed conditions: type at least two letters to search the international SNOMED list. Choose one or more conditions from the results.
- Care team: choose which members of this patient's Care Team are working on this plan. Does the patient not have a care team yet? Then this field isn't available.
- Period start and Period end: fill these in yourself, in the format yyyy-mm-dd. There's no date picker.
TIP
When you expand a care plan, you'll also see a "Contributors" list. These aren't the same people as the chosen care team: this field is determined automatically by Sophia, and you can't adjust it yourself.
Deleting a Care Plan
Click Delete at the bottom of the expanded care plan. Sophia asks for confirmation.
Activities Within a Care Plan
Expand a care plan, and click the plus icon next to Activities to add one.
- Performed activity: a free description of what was done. This field is required.
- Appointment: optionally link this activity to a specific appointment of the patient.
Both fields are independent of each other: you can fill in just a description, just link an appointment, or both.
Also Logging the Activity as a Comment
When creating an activity, you can tick the box Log to comment logbook. Then choose a comment type:
- Free text: simply uses the activity's description.
- Contact report, Anamnesis, or Interpretation: opens the same extensive form you know from the Comments tab.
Click save, and Sophia first creates the comment, then links the activity to it. Such a comment then also just appears among the patient's other comments.
TIP
This is only available when creating a new activity. When editing an existing activity, this checkbox is no longer available.
Editing or Deleting Activities
Use the icons next to an activity in the table. Deleting always asks for confirmation.
Medication
Further down the same page, you find a simple list of the patient's medication, each identified by a CNK code. You can add, edit, or remove medication.