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Medication history has an additional Add functionality
Personal History(Habits/Risk factors)
It's essential to gather information about a beneficiary's personal history, including any risk factors or habits that might impact their health. Here's an outline of how you might delve into these categories:
- Previous Tobacco History:
Smoking Habits: Record any previous smoking habits, including duration, frequency, and quantity. This involves cigarettes, cigars, pipes, or any other tobacco products.
Duration of Use: Note the period during which tobacco was consumed regularly.
Cessation Attempts: Explore if there have been any attempts to quit smoking and their success.
- Previous Alcohol History:
Drinking Patterns: Understand the frequency and quantity of alcohol consumption.
Duration of Use: Note the duration over which alcohol has been consumed.
Alcohol-related Issues: Inquire about any related problems such as dependency, accidents, or health complications.
- Previous Allergy History:
Known Allergies: List any known allergic reactions to specific substances, foods, medications, or environmental triggers.
Severity: Gauge the severity of allergic reactions experienced in the past.
Treatment and Management: Explore how allergies have been managed or treated previously.
Additional Considerations:
Dietary Habits: Enquire about the typical diet patterns, including preferences, any specific diets followed, and nutritional intake.
Exercise Routine: Gather information about physical activity levels and exercise routines.
Medical History: Include any past medical conditions, surgeries, or chronic illnesses that might impact their health.
When collecting this information, it's crucial to maintain confidentiality and create an open and non-judgmental environment to encourage honest disclosure. This data is essential for healthcare professionals to understand and manage potential health risks and tailor appropriate interventions or guidance for the beneficiaries' well-being.
Family History
Family medical history is a comprehensive record detailing the health conditions and illnesses experienced by the relatives of the Beneficiaries. This historical data is crucial in understanding and assessing potential health risks and genetic predispositions among family members. The family medical history is divided into several key categories:
1) Disease Types:
Family members have encountered various health conditions, including but not limited to:
Asthma
Diabetes Mellitus
Epilepsy (Convulsions)
Hemiphelgia (Stroke)
Hypertension
Infant and Congenital Anomalies
Ischemic Heart Disease
Multiple Pregnancy (Nil)
2) Affected Family Members:
Details regarding specific family members who have been afflicted by the aforementioned diseases:
Brother
Sister
Father
Mother
Daughter
3) Past Family History:
Accessing the previous medical history of the Beneficiary's family members involves clicking on an icon, which prompts a pop-up display presenting the relevant historical medical information.
4) History of Genetic Disorders:
This section delineates any disorders or diseases prevalent among the family members of the Beneficiaries. It includes a dropdown selection:
Yes
No
Once clicking yes on H/O Genetic disorders then a free text for Genetic disorders appear on the screen.
5) Consanguineous Marriages:
Refers to unions occurring within the same family or blood relations. It is divided into dropdown selections:
Yes
No
Add and Remove Button
Within this system, several crucial components demand the inclusion of additional information regarding a patient's health. Each of the following aspects: Further Illness or Surgery, Comorbidity or Concurrent Conditions, Medication History, Personal History (Habits/Risk Factors), and Family History necessitates thorough documentation. To facilitate this, an 'Add' button is incorporated across all functionalities. This button serves the purpose of capturing any additional details pertaining to these areas. If there are new instances or updates related to any of these categories, users are required to click on the 'Add' button to ensure comprehensive data capture.
Upon clicking the cross symbol associated with any added field, the system will initiate the deletion process for that particular entry. This action effectively removes the additional field from the interface, streamlining the information and ensuring a cleaner, more organized display of data."
After clicking on next it goes to Anthropometry screen
Anthropometry
Anthropometry is the scientific study of the measurement and proportions of the human body. It involves taking accurate measurements of various body parts and dimensions to understand human physical variation, growth, and development. This field is utilized in various disciplines such as anthropology, ergonomics, medicine, nutrition, and sports science.
Categories of Anthropometry:
Anthropometry encompasses various crucial measurements that shed light on human body composition and structure. These measurements include:
Height (CM): The vertical measurement from the base to the top of an individual, providing insights into growth patterns and stature.
Weight (kg): The quantitative assessment of body mass, crucial for understanding health, fitness, and nutritional status.
Body Mass Index (BMI): A calculated index using an individual's weight and height, aiding in categorizing weight status and health risks.
Waist Circumference (cm): Measurement around the narrowest part of the abdomen, significant in assessing abdominal fat and associated health risks.
Hip Circumference (cm): Measurement around the widest part of the hips, contributing to assessments of body shape and potential health implications.
Waist-to-Hip Ratio: Calculated ratio between waist and hip circumference, offering insights into body fat distribution and associated health risks.
Note:-Weight(kg) is checked with the help of Device called as Healthcube
Vitals
Vital signs indeed play a critical role in assessing an individual's health status and are fundamental in various medical evaluations and treatments. These measurements encompass several key physiological parameters that indicate the body's overall functioning. The primary vital signs typically include:
Temperature (°F):
Temperature measurement is essential in gauging the body's heat balance and detecting potential signs of fever or hypothermia. It is typically recorded in degrees Fahrenheit (°F).
Pulse Rate (Per Min):
Pulse Rate
Pulse rate refers to the number of heartbeats per minute (bpm) and reflects the heart's functioning. It's commonly measured at arterial points and is an integral component of cardiovascular assessment.
SPO2% (Oxygen Saturation):
SPO2%(Oxygen Saturation):
SPO2, or peripheral capillary oxygen saturation, denotes the oxygen saturation level in the blood. It is a measure of how much oxygen the blood is carrying, usually expressed as a percentage.
Blood Pressure (BP):
Blood Pressure (BP)
Blood pressure is the force exerted by circulating blood against the walls of blood vessels. It comprises two measurements:
Systolic BP (mmHg): The pressure in the arteries when the heart contracts.
Diastolic BP (mmHg): The pressure in the arteries when the heart relaxes between beats.
It is represented in millimeters of mercury (mmHg) and is critical for assessing cardiovascular health.
Respiratory Rate (min):
Respiratory Rate(Min)
Respiratory rate signifies the number of breaths taken per minute. It is a vital parameter in assessing lung function and overall respiratory health.
Random Glucose Test
RBS test is a simple blood test used to measure the amount of glucose present in the bloodstream at a given time, regardless of when the individual last ate. Elevated blood sugar levels beyond the normal range can indicate various conditions, with diabetes being one of the primary concerns.
Random Glucose test is divided into following categories
RBS Result(mg/dl)
The result of RBS is typically measured in milligrams per deciliter (mg/dL).
RBS Test Remarks
The remarks or interpretation of RBS (Random Blood Sugar) test results can vary based on the measured glucose level in the blood. Here are some possible remarks or interpretations
Examination
General Examination
The general examination is a visual and manual examination to collect, in a reasonably short time, information that can be combined with the signalaient, history, and general impression to guide the problem formulation and give direction to further examination.
General examination is divided into following categories which are as follows
1.Consciousness
Consciousness is a complex and multifaceted phenomenon that refers to the state or quality of being aware of and able to perceive both internal and external stimuli. It involves subjective experiences, sensations, thoughts, feelings, and perceptions. While it is a fundamental aspect of human experience, the exact nature and mechanisms of consciousness remain a topic of ongoing debate and exploration in various fields such as philosophy, psychology, neuroscience, and cognitive science
It is divided into three categories
a) Conscious
Conscious is a person having mental faculties but not dulled by sleep ,faitness or stupor.It also includes perceiving, apprehending or noticing with a degree of controlled thought or observation
b) Semiconscious
Semiconsciousness refers to a state that lies between full consciousness and unconsciousness. It implies a diminished level of consciousness where a person may have some awareness of their surroundings or internal experiences but is not fully alert or responsive.
c)Unconscious
When someone is unconscious in a medical context, it means they are not responsive to stimuli and cannot be awakened. This state can result from various causes, such as trauma, medical conditions, intoxication, or underlying health issues.
All these are in the form of Dropdowns
Cooperation
Cooperation in the medical context refers to the collaborative relationship between healthcare providers (such as doctors, nurses, specialists, therapists, and other professionals) and patients or their families. It involves mutual understanding, communication, and shared decision-making to achieve the best possible outcomes in healthcare.
Cooperation is divided into following categories
a)Cooperative
Cooperation in the medical context refers to the collaborative relationship between healthcare providers (such as doctors, nurses, specialists, therapists, and other professionals) and patients or their families. It involves mutual understanding, communication, and shared decision-making to achieve the best possible outcomes in healthcare.
b) Irritable
Irritable" in a medical context often refers to a symptom or condition related to increased sensitivity or a tendency to react strongly to stimuli.
c)Restless
Restless typically refers to a state of agitation, unease, or the inability to stay still or relax.
Kindly find the screenshot in which it is in the form of dropdowns
Built and appearance
The classification of body types based on build or appearance can vary. While there isn't an exact standard classification universally adopted, general terms might be used to describe different body builds. Here's an overview:
a)Thin Build: Individuals with a thin build typically have a lean and slender physique. They tend to have smaller frames, less muscle mass, and lower body fat compared to other body types. Some medical conditions or lifestyle factors might contribute to being thin, such as a high metabolic rate, certain illnesses, or genetic factors.
b)Moderate Build: This category usually refers to individuals who have an average or moderate body size and composition. They neither fall into the thin nor heavy build categories. They might have a relatively balanced proportion of muscle and fat, without being notably lean or overweight.
c)Heavy Build: This term is often used to describe individuals who have a larger or heavier body size. They might have a higher percentage of body fat or a more substantial muscular build. It's important to note that a heavy build doesn't necessarily equate to being unhealthy .It’s more about a larger physical presence or higher body weight compared to thin or moderate builds.
The General examinations encompass several additional features, crucial to their comprehensive nature. Some of these key components include
1)Coherent
Coherent refers to the quality of being logical, consistent, and interconnected. It describes a state where different pieces of information, symptoms, or findings fit together logically, forming a unified and understandable picture or explanation. In medical contexts, coherence often relates to the consistency of symptoms, test results, and the overall clinical presentation of a patient, aiding healthcare professionals in making accurate diagnoses and treatment decisions based on a cohesive understanding of the situation.
There are two dropdowns in coherent which are
a) Yes
b) No
2) Comfort
Comfort assessment is a critical aspect of evaluating the well-being of an individual following a comprehensive examination. It involves the categorization of the beneficiary's state into comfortable or uncomfortable conditions, which further helps identify specific discomfort indicators.
Comfort Categorization:
a)Comfortable: Refers to a state where the beneficiary exhibits signs of being at ease and without evident discomfort.
b)Uncomfortable: Signifies a condition where the beneficiary shows signs or indicators of discomfort, requiring closer attention and further assessment.
Uncomfortable Subcategories:
When assessing discomfort, various indicators or subcategories may manifest in the beneficiary. Some of these discomfort indicators include:
Danger Signs: Observable indications that suggest an immediate threat to the beneficiary's health or well-being.
a)Fast Breathing: Increased respiratory rate beyond normal ranges, signaling potential respiratory issues or distress.
b) Chest Indrawing: Visual inward movement of the chest during breathing, often a sign of breathing difficulties.
c)Stridor: Audible high-pitched breathing sounds resulting from narrowed airways, indicating respiratory distress.
d)Grunt: Audible sound produced during expiration, commonly associated with breathing difficulties, especially in infants or young children.
e)Respiratory Distress: General difficulty in breathing or inadequate oxygen intake, leading to visible distress.
f)Cold and Calm Peripheral Pulses: Abnormalities in peripheral pulses characterized by coldness and calmness, potentially indicative of circulatory problems.
g) Convulsions: Involuntary and sudden muscle contractions, often associated with neurological issues or seizures.
h) Hypothermia: A dangerously low body temperature that can indicate a critical health condition requiring immediate attention.
Below is the screenshot for the reference
3) Gait
In medicine, gait refers to the pattern of movement and manner of walking. It encompasses the way a person walks, including their posture, rhythm, speed, stride length, and the coordinated movement of various body parts involved in walking. Assessing a person's gait is an important part of a physical examination because changes or abnormalities in gait can be indicative of various medical conditions, injuries, or neurological issues. Observing and analyzing someone's gait can provide valuable information to healthcare professionals in diagnosing or monitoring certain disorders affecting the musculoskeletal system, nervous system, or other body systems.
Gait is divided into following categories
a) Normal Gait:
Normal gait refers to the typical, smooth, coordinated, and efficient walking pattern exhibited by individuals without any apparent impairment or abnormality in their walking pattern.It involves a rhythmic and coordinated sequence of movements involving the legs, hips, and feet, allowing individuals to walk comfortably, with balance and stability.
b) Limping:
Limping, also known as an abnormal gait, is characterized by an uneven or irregular walking pattern due to pain, injury, weakness, or other underlying medical conditions affecting the legs, hips, or feet.
It involves an altered gait pattern, where the individual may favor one leg or exhibit an uneven distribution of weight while walking, often resulting in a noticeable limp or asymmetrical movement
4) Danger signs
"Danger signs" in a medical examination refer to specific indicators or symptoms that suggest a severe or life-threatening condition requiring immediate attention or intervention. These signs are crucial in identifying patients who are critically ill and in need of urgent medical care. Some of the common danger signs include the following dropdowns
a) Yes
b) No
Once clicking on Yes there appears another fields known as Danger sings and it is following into following dropdowns which are in the form of checkbox which are
a)Fast Breathing
b)Chest Indrawing
c)Stridor
d)Grunt
e)Respiratory distress
f)Cold and calm peripheral pulses
g)Convulsions
h)Hypothermia
i)Delirium
j)Uncontrolled Breathing
k)Hematemesis
l)Refusal of feeds
5)Pallor
"Pallor" refers to an unhealthy pale appearance of the skin. It's a clinical observation that can be noted during a physical examination of a patient. Pallor can be present or absent based on whether the skin appears pale or not.
Pallor is divided into following dropdowns
a)Present
If the skin appears notably paler than usual, it could indicate various underlying conditions such as anemia, shock, reduced blood flow, or decreased oxygenation of the blood.
b)Absence
If the skin color appears normal, without any significant paleness, it suggests that the patient doesn't exhibit this particular sign of pallor.
6)Jaundice
Jaundice is a condition produced when excess amounts of bilirubin circulating in the blood stream dissolve in the subcutaneous fat (the layer of fat just beneath the skin), causing a yellowish appearance of the skin and the whites of the eyes.
There are two types of Jaundice which shows whether Patient is undergoing Jaundice oe Not
a) Yes
b) No
7)Cyanosis
Cyanosis is a medical condition characterized by a bluish discoloration of the skin, mucous membranes, or nails. It occurs when there is a decreased level of oxygen in the blood. This bluish tint is most noticeable in areas where blood vessels are closer to the skin's surface, such as the lips, fingertips, nails, or the skin under the eyes.
There are two dropdowns in Cyanosis
a) Present
b) Absent
9)Lymphadenopathy
Lymphadenopathy refers to the enlargement or swelling of lymph nodes. Lymph nodes are small, bean-shaped structures that are part of the lymphatic system, which plays a crucial role in the body's immune system. They are distributed throughout the body and act as filters for harmful substances, such as bacteria, viruses, and abnormal cells.
There are two dropdowns in Lymphadenopathy
a) Present
b) Absent
10)Edema
Edema refers to the swelling caused by excess fluid trapped in the body's tissues. It occurs when small blood vessels leak fluid into nearby tissues, leading to an abnormal accumulation of fluid. This buildup can happen in various parts of the body, such as the hands, arms, feet, ankles, and legs, or it can affect other areas, including the lungs or abdomen.
There are two Dropdowns in Edema
a) Present
b) Absent
Head to Toe examination
A head-to-toe examination is a comprehensive physical assessment conducted by healthcare professionals, such as doctors, nurses, or physician assistants. It involves systematically examining all parts of a patient's body, starting from the head and progressing down to the toes. The purpose of a head-to-toe examination is to assess a patient's overall health, identify any abnormalities, evaluate the functioning of various body systems, and detect potential health issues.
Under Head-to-toe examination select
a) Normal or
b) Anormal
After selecting Abnormal enter the following details in the screenshot such as
- Head
- Eyes
- Ears
- Nose
- Throat
- Oral cavity
Now click on Submit
Doctor Module
Select the Beneficiary from the Doctor list
After clicking on the Beneficiaries, the details which was entered in Nurse Module will be displayed in Doctor Module
The chief complaints entered by Nurse will be displayed in the Nurse Module
Next go to CDSS (Clinical decision support system and Doctor will check whether all details are entered correctly by Nurse and if any changes required then it can be edited from Doctor end
Next upload the files if any files relating to Beneficiary previous history or any other information
Click on Next and proceed to case Record section
Next Move to History section and Doctor will check the past history of the Beneficiaries
Now click on Next and enter Anthropometry details
Now enter the two details which are
- Anthropometry details
- Vitals
Click on Next and enter the Examination details
After entering the examination details click on Next move to Case record section
Case Record section
Here there are following sections in Case Record section
Previous Significant findings will include the past clinical findings of the Beneficiaries
"Next, click on 'Previous Visit Details' to view a comprehensive overview of past visit records for all beneficiaries. This section includes information on current vitals and blood pressure readings."
Next click on Finings and select the following things such as
a) Chief complaint-Select the following chief complaint from the card such as Fever or cough and also enter Duration , Unit of Duration and Description
b) Clinical Observation-Search the clnical observations from the algorithms
c) Significant findings- Search the significant findings from the algorithms
d) other symptoms: - Enter any other symptoms if applicable
Add or Remove Chief complaints, Clinical observations and significant findings if any
Now select Provisional Diagnosis as it is mandatory to select and also enter specialist advice if any
Next click on Investigations and select the following such as
a) Test Name
b) Radiology and Imaging
c)External Investigations if any
Next enter the Prescription details
Click on Reports to access all the reports such as Lab test reports , Radiology reports and Achieved Reports
"Click on 'Next' to proceed to the 'Revisit' and 'Refer' sections." For referring to Higher Health center
Now click on Submit and proceed to Lab technician Module
Click on Beneficiary and proceed to Lab test screen
Next enter the lab test and proceed to Doctor screen where all the lab details will be entered
Now the Lab test is completed, and it will show in the worklist of Doctor in Yellow color since lab test is completed
Now Reports will be generated for the Beneficiaries for all the tests that has been conducted
