Recording Vital Signs and Test Results in Med-Center

Introduction This technical note discusses Med-Centers ability to record and plot lab test results or patient vital signs. This capability is a new addition to Med-Center as of version 4.3. The patient care record was modified to include sections to add and view patient Vital Signs or Tests (see Figure 1).

Figure 1 - List of Tests within Patient Care Record Discussion Test definitions include a brief description, user definable test type, status, related diagnosis, and identification of who initiated the test. The test results may have one or a multitude of discrete test result elements that make up the test. Each test result has a description, a result value, an assessment (such as Positive, Negative, Normal, Abnormal , High , or Low), and a comment area. The result value can accept either numeric (which can be plotted) or text entries (which cannot be plotted). Figure 2 shows definition of a test (the example shows a typical blood test), with results being added using the available blood test template.

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Technical Note Recording Vital Signs and Test Results

Figure 2 - Defining a Test and Adding Test Results The template feature allows commonly administered test results to be entered easily and quickly. The results area behaves like a spreadsheet and allows the tab key to quickly move to the next enterable field (shown in light pink). If a template item has no enterable test information, the Show current radio button, when selected, will show only the defined results of the test (see Figure 3). Figure 3 also shows that the results area no longer accepts test entries (cells no longer have light pink color) because the provider has acknowledged / signed the Test & Results record.

Figure 3 - Current Results and Provider Acknowledgement Med-Center v4.3 Database Constructs Page 2 of 7

Technical Note Recording Vital Signs and Test Results

Templates (or Test Sets) may be defined by pressing the templates icon button shown next to the templates list. The Test Set Editor (see Figure 4) allows test sets to be created, modified, or deleted as needed. Note that administrator privileges are needed to use the Test Set Editor. Test sets may be defined to provide test result templates or vitals templates. If the checkbox is set to Use as Vitals set, the defined template will be available when entering vital sign information. User definable vital sign sets are useful to extend the standard vital signs (i.e., BP, weight, height, pulse, heart rate, and temperature) to include specialty specific vitals (e.g., for OBGYN fetal vitals). This gives unlimited flexibility in the practice or multiple department clinic.

Figure 4 - Test Set Editor

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Figure 5 - Selecting Options to Print or Plot Printing and Plotting Printing or plotting the test results are initiated by selecting the Options button on the Patient Care record Tests screen. Plotting considers all of the results of the same definition across all of the test dates. Figure 6 shows typical plot results by selecting the parameter of interest.

Figure 6 Typical Plot of a Test Result

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Technical Note Recording Vital Signs and Test Results

A slider allows quick selection of all of the results or a subset considering the most recent result dates. An option to write the information to a file is available to allow plotting or analysis by other applications. Figure 7 shows a report that could be printed and given to the patient.

Figure 7 - Printed Results Vital Signs The vital signs screen (see Figure 8) shows the standard vital signs for quick assessment by the clinician from the Patient Care record. If extended vital signs have been defined, this is noted by the checkbox. Entry of vital signs is similar to the entry of test results.

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Figure 8 - Vital Signs List

Figure 9 - Vital Signs Entry Screen Vital signs may also be printed and plotted similar to the test results (Figure 10). Med-Center v4.3

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Figure 10 - Vital Signs Plotting Summary Tests and test results may be stored within Med-Center and can be accessed throughout the office, printed for review, given to the patient, plotted, or written to a file for use with a spreadsheet application or analysis program.

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