Care documentation

Care documentation comprises a number of modules which separately and jointly simplify the daily routines of documenting, communicating and scheduling as well as the processing of information and data.

The “Letter” function is used for writing letters to patients, care units and public authorities. Templates and print layouts make it easy to write letters. The printouts are generated according to the graphic profile used by the care unit. Letter templates can be defined using tags which automatically retrieve and translate current information for the letter.

An advanced function makes it possible to design forms in the system. A form can have various input and presentation objects. The form is linked to a PDF document which is either created locally or downloaded from a public authority like Försäkringskassen (national health insurance). Data in the form can be identified using terms in the term index which can be used for exporting to data storage devices and other systems. The fields of the form can be automatically filled in with information from the patient’s medical records or from other parts of the system. The module is adapted for sending electronic forms.

Case note
“Diagnosis Overview” is a comprehensive function for viewing and recording all of a patient’s diagnoses. By entering specific search words in “Medical Records Text”, the diagnosis can be entered in the records according to ICD-10 and ICD-10P. The overview provides various fields for the patient’s diagnosis list, chronic diagnoses and diagnoses on alert.

The “Medical Records Text” module processes current information documented during the patient contact process. This information is recorded using templates structured with search words that are defined in TakeCare’s term index. This helps the user to follow a certain structure and makes it possible to export data from medical records to external databases, such as a QA database. The Medical Records Text function complies with the patient data law’s provisions relating to the handling of corrections and automatic locking. To facilitate the finding of information, TakeCare has equipped Medical Records Text with a filter. This is used for isolated filtering or filtering in various combinations using parameters like care unit, record template, occupational group or query term.

Patient demographic
The “Chronological Documents” function provides an overview of all the documents in a patient’s medical records. The documents are presented as a summary of the documents and are listed in chronological order. It is easy to click one’s way to the actual underlying document. It is also possible, using preset filters, to limit the contents to make it easier to find the information desired in the medical records.

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