Report - ems

The Report step records the following:

Diagnosis
Any additional free text comments without repeating previous recordings
Follow up action required
RTT Outcomes and OPCS-4 codes (optional setting)
Report sign off
Report issue for printing

Diagnosis

Click on the Diagnosis button to open pop up to enable select of Normal or suspected / confirmed diagnosis. Click OK to close. Selected details will appear in summary on screen.

Selected details will appear in summary on screen.

Recording Normal Diagnosis for Upper GI procedures

A single 'Normal' button has been included in the Upper GI procedures, when selected all related anatomical areas will be defaulted to record a diagnosis of Normal.

Pathology

The user can review the pathology information by clicking on the View Pathology button below the Sign Off Report Sign field

Follow Up

This allows the user to record the appropriate Follow Up decision made at the end of the procedure.

Depending on the follow up decision selected, the user will be presented with various options to complete. For brevity, all options have been selected.

Note: When Further endoscopic procedure has been selected, a partial booking is created. This functionality is used for surveillance patients (see EMS Follow-Up).

Optional setting: Recording RTT Outcome and OPCS-4 codes, requires setting to be enabled in System Configuration and completion can be made mandatory if desired.

Generating the Procedure Report

Preview
The procedure report can be previewed prior to electronic sign off. The preview action creates a set of reports, which can be viewed online. This report will have a clear watermark visible on the report to indicate to users that the report has not been authorised.

Sign Off Report
Once the report is finalised, electronic sign off is required.
To sign off the report, enter the password into the box and click the Sign Off button. Only users with Endoscopist permissions can sign off a report. The button will be greyed out if Endoscopist permission has not been granted to the user.

The procedure data will collate and screen changes to indicate that the report has been signed off and user can issue procedure reports. The user can Undo the Sign Off by entering the password and clicking the Undo Sign Off button.

Issuing Procedure Reports
Click Issue Reports button, user will be presented with report selection options. If Images have been taken, this selection will appear on the list.

The user selects the report required and amends the number of copies required for various recipients. A default setting is applied initial, which is a global setting and cannot be changed for individual users.

Report Recipients
On all issued copies of the Procedure Reports, a record of recipients has been included.

If the report has been re-issued, the original recipient's information is retained and additional information indicating the 'Reissued' date and recipients that have been added.