Overview
Medical Records & History is an essential component of the KiviCare EHR system, designed to streamline healthcare management processes. This feature integrates seamlessly with other modules to provide a comprehensive solution for medical practices.
Key Features
- Easy to use and intuitive interface
- Seamless integration with existing workflows
- Comprehensive data management capabilities
- Real-time updates and notifications
- Customizable settings and configurations
Getting Started
To begin using Medical Records & History, follow these simple steps:
- Navigate to the appropriate section in your KiviCare dashboard
- Configure the necessary settings according to your requirements
- Test the functionality to ensure everything works as expected
- Train your staff on how to use this feature effectively
1. Medical Records Overview
KiviCare provides a structured and comprehensive system for documenting a patient’s medical information during an encounter. These records help healthcare providers:
- Understand a patient’s past and current medical conditions
- Track health progress over time
- Make informed and accurate clinical decisions
All medical records are stored per encounter and contribute to the patient’s overall medical history.
2. Components of Medical Records
Medical records are managed from the Encounter Dashboard, primarily within the Clinical Details section. The records are divided into the following components:
2.1 Medical History
Purpose
Used to record a patient’s past medical background.
Includes:
- Chronic illnesses
- Past surgeries
- Allergies
- Family medical history
Usage:
- Select from a predefined list of common conditions (e.g., Diabetes, Hypertension).
- Add custom history entries if the required condition is not available in the list.
Medical History provides long-term context and is useful across multiple encounters.
2.2 Medical Problems
Purpose
Used to document complaints, symptoms, or diagnoses related to the current visit.
Usage:
- Search and select entries from the Clinical Problems list.
- Multiple problems can be added per encounter.
These entries help doctors define and record the primary reason for the visit.
2.3 Observations
Purpose
To record clinical findings observed during physical examination.
Usage:
- Add observations such as:
- High blood pressure
- Swelling
- Pale skin
- Select from the Clinical Observations list or create new entries.
Observations capture objective findings that support diagnosis and treatment planning.
2.4 Notes
Purpose
A free-text section for detailed clinical notes.
Usage:
- Write detailed examination notes
- Record patient statements
- Add private remarks for internal reference
Notes are stored as part of the encounter and can be restricted from patient view if required.
2.5 Medical Reports
Purpose
To store external or supporting medical documents.
Usage:
- Upload files such as:
- Laboratory reports
- X-ray or scan images
- Prescriptions from other doctors
Supported Formats:
- Images: JPG, PNG
- Documents: PDF
Features:
- Uploaded reports can be previewed directly in the Encounter Dashboard.
- Reports remain linked to the patient for future reference.
3. Managing Medical Records
3.1 Adding Records
- Open an active Encounter.
- Go to the Clinical Details tab.
- Locate the relevant section (Medical History, Problems, Observations, etc.).
- Start typing to search or add a new entry.
- Press Enter or click Add to save the information.
3.2 Deleting Records
- Click the “X” icon next to any added item.
- The entry is removed immediately from the encounter.
Deletion permissions may depend on user role and encounter status.
3.3 Using Templates
- Frequently used combinations of medical history, problems, or notes can be saved as Encounter Templates.
- When creating a new encounter, applying a template will automatically populate these fields.
Templates help maintain consistency and reduce data entry time.
4. Access Control & Privacy
Access to medical records is controlled by user roles and clinic privacy settings.
Role-Based Access
- Doctors
- Full read/write access to all medical records
- Patients
- Can view their own medical history and reports via the Patient Dashboard (if enabled)
- Receptionists
- Access may be limited or restricted based on clinic configuration
- Typically cannot edit sensitive clinical information
5. Medical Records Best Practices
- Always record Medical History before adding prescriptions.
- Keep Medical Problems specific to the current encounter.
- Use Observations for measurable or visible findings.
- Upload reports in clear, readable formats.
- Use templates for recurring visit types to save time.
This completes the Medical Records & History documentation for KiviCare.
Best Practices
To get the most out of Medical Records & History, consider implementing these best practices:
- Regular Updates: Keep your system updated to access the latest features and security patches
- Staff Training: Ensure all users are properly trained on the functionality
- Data Backup: Regularly backup your data to prevent loss
- Documentation: Maintain internal documentation of your specific configurations
Troubleshooting
If you encounter any issues with Medical Records & History, try the following troubleshooting steps:
- Clear your browser cache and cookies
- Verify that you have the necessary permissions
- Check for any plugin conflicts
- Review the system logs for error messages
- Contact support if the issue persists
Related Resources
For more information about Medical Records & History and related features, check out these additional resources:
- KiviCare Video Tutorials
- Community Forum Discussions
- Official Documentation Portal
- Support Ticket System
Conclusion
Medical Records & History is a powerful feature that enhances your KiviCare EHR experience. By following this guide and implementing the best practices outlined above, you’ll be able to leverage this functionality to its full potential. If you need further assistance, don’t hesitate to reach out to our support team.