# Medical Records FAQs ### Start Consultation #### 1. How to start the Consultation in the Current and Past Medical Records? A hyperlink is available on each patient visit in the **Current** and **Past Medical Records**, redirect you to the **Medical Records** screen for consultation. Alternatively, you can use the **Start Consultation** hyperlink available on the **Appointment Card** in the **Scheduler** screen to access the same functionality. *** ### Diagnosis and Templates #### 1. How do I add a Diagnosis for the Visit? After starting the consultation, go to the **Diagnosis** tab to record the relevant diagnosis details. Using the Search Field or ICD hyperlink. #### 2. How do I create a Template in Medical Records? After starting the consultation, go to the **Diagnosis** tab. In the **Diagnosis** section, you can enter/select the patient’s diagnosis details. Next, select the **TEMPLATE** hyperlink to diagnosis as a template. #### 3. How do I use a template in Medical Records? After starting the consultation, go to the **Diagnosis** tab. In the **Diagnosis** section, click the **Template** hyperlink, this action opens the pop-up screen. Select the template you want to use for the visit, and then choose **Append** or **Overwrite** to apply the template. *** ### Medical Records and VAT Management #### 1. How do I add a 5% VAT for an item in Medical Records? After starting the consultation, go to the **Diagnosis** tab. In the **Diagnosis** section, click the **PRICE CARD** hyperlink to open the pop-up screen. Select the required items, then check the **Cosmetic in Nature** checkbox to add them to the section. *** ### Visit Details and Vital Information #### 1. How do I copy the details from the Last Visit and paste them into the Current Visit? After starting the consultation, go to the **Journey** tab and select the respective visit. Click the **COPY** icon to open the pop-up, where you can choose to **APPEND** or **OVERWRITE**. #### 2. What are the different ways to capture Vital Values in Medical Records? There are multiple ways to capture vital values in the **Medical Records** screen: 1. **SOAP tab**: In the **Diagnosis** tab, click **Expand** icon on the **Patient Vitals** section to open it and record the patient’s vitals. 2. **Patient Vitals button**: Click the **Patient Vitals** button in the right panel to open a slide-up popup where you can enter the vitals. 3. **Pre Check tab**: Vitals can also be recorded in the **Pre Check** tab. *** ### Pregnancy and Visit Data Management #### 1. Is there an option to capture Pregnancy information? Yes, based on the patient's gender mentioned in the **Patient Register**, the **Pregnancy** dropdown menu appears in the **Patient Vital** section for female patients. It will not appear for male patients. #### 2. Is there an option to copy the previous visit data in the Casesheet? Yes, using the **Copy from Previous** button, you can copy the data from the last visit to the current visit if it is the same Casesheet. *** ### Miscellaneous #### 1. How do I unlock the locked (read-only mode) Medical Records screen? Patient files may become locked on the **Medical Records** or **Patient Register** screen if the application is not closed properly. This occurs when a user opens a record and closes the browser window or tab instead of navigating back or completing the visit. As a result, the application assumes the file is still in use and keeps it locked. #### Unlocking a Locked Record * If the same user who locked the file opens it again, the record will be unlocked. * To unlock the file for another user, an Admin or Authorized Staff member must remove the lock using the **Release Lock** screen.\ \ **Steps to Release a Lock** * Open the **Release Lock** by navigating to **Home > My Tasks > Release Lock**. * Select one or multiple locked entries from the list. * Click **RELEASE LOCK** to remove the lock. Once unlocked, other users can access the file. #### 2. How do I enable the Highlights icon in the Medical Records screen? An admin or authorized staff can enable the Highlights icon by following these steps: * Open the **Application Configuration** screen by navigating to **Home > Setup > Application Configuration**. * In the **Users** dropdown, select the required user. If no user is selected, the configuration will apply to all users in the clinic. * From the left panel, select **Medical Records**. * In the right panel, expand the **Patient Highlights** section. * Toggle on the **Patient Highlights Icon In Medical Records** switch. The Highlights icon will now appear in the **Diagnosis**, **Casesheet**, and **Medication** tabs within the Medical Records screen. #### 3. How do I provide nurses access to a clinician’s Medical Records files to add precheck details and nurse notes? To enable nurses to add precheck values and nurse notes in a clinician’s Medical Records files, the nurse must be associated with the respective clinician. An admin or authorized staff can set this up by following these steps: * Open the **Users (Home > Admin > User Setup > Users)** screen. * Use the **Search** field to locate the specific user. Click the **Edit** icon to open the user account. * Navigate to the **User Group Settings** tab. Use the **Associated User** section to link the appropriate doctor to the account. * Click **SAVE**. Once saved, the nurse will be able to access the selected clinician’s patient records and update precheck and nurse note sections. #### 4. How do I view a patient’s past medical history (Journey)? You can view a patient’s past medical history from the **Journey** tab, available in both the **Patient Register** and **Medical Records** screens. **To view from the Patient Register:** * Open the **Patient Register** by navigating to **Home > Patient > Patient Register**. * Search for an existing record using the Patient PIN, Name, EID, or Mobile No. in the **Search** field. * Select the respective patient from the list. * Navigate to the **Journey** tab to view the patient's past visit and treatment history. **To view from the Medical Records screen:** * Open the **Medical Records** screen by navigating to **Home > Patient Queue > Medical Records**. * Navigate to the **Journey** tab to view the patient's historical medical data. #### 5. How to enable the File Upload option if it is not showing in Investigation Items in the Medical Records? Only an admin or authorized staff member has the access rights to update the settings in **Application Configuration.** Follow these steps to enable the setting: * Open the **Application Configuration** screen by navigating to **Home > Setup > Application Configuration**. * Select the appropriate user from the **Users** dropdown to enable the setting. * From the left panel, select **Medical Records**. * Expand the **Tab File Configuration** section. * Enable the toggle switches under the **Test** (Investigation) section. #### 6. How to enable the Patient Highlights icon when it is not showing in Medical Records? Only an admin or authorized staff member has the access rights to update the settings in **Application Configuration.** Follow these steps to enable the setting: * Open the **Application Configuration** screen by navigating to **Home > Setup > Application Configuration**. * Select the appropriate user from the **Users** dropdown to enable the setting. * From the left panel, select **Medical Records**. * Expand the **Patient Highlights** section. * Enable the **Patient Highlights Icon In Medical Records** toggle switch. #### 7. How do I remove a document that was mistakenly added? The uploaded file can either deleted in the **Patient Register** or **Current Medical Records** screen. #### Medical Records * After starting the consultation in the **Current Medical Records** **(Home > Medical Records > Current Medical Records)** screen. * Navigate to the **Document** tab, choose the respective folder and file. * Click the **Delete** icon. A prompt message appears for confirmation to delete the details. Click **YES** to remove the file. #### Patient Register * Open the **Patient Registe**r by navigating to **Home > Patient > Patient Register.** * Search for an existing record using the Patient PIN, Name, EID, or Mobile No. in the Search field. Select the respective patient from the list. * Navigate to the **Document** tab, choose the respective folder and file. * Click the **Delete** icon. A prompt message appears for confirmation to delete the detials. Click **YES** to remove the file. #### 8. Why are the casesheets not visible under the Casesheet tab in the Medical Records screen? If casesheets exist in the system but are not appearing in the **Casesheet** tab, they may not be mapped to the clinic or user. Follow these steps to map the casesheets appropriately: * Open the **Casesheet Mapping (Home > Configurator > Casesheet Mapping)** screen. * Use the **Search** field to find the casesheet. If the casesheet is visible in the list, click it to map it to the relevant clinic, department, doctor, or speciality. * In the **Casesheet Mapping** section, select the **Clinic**, **Department**, **Doctor**, and **Speciality** from the dropdown lists. To apply the mapping to all departments, select only the **Clinic** from the dropdown. Customize the mapping for specific departments, doctors, or specialties as needed. * Click **Add** to save the mapping. #### 9. How do I enable or disable the Treatment Plan tab in the Medical Records screen? Admin or authorized staff member can enable or disable the **Treatment Plan** tab by following these steps: * Open the **Application Configuration** screen by navigating to **Home > Setup > Application Configuration.** * In the **Users** dropdown, select the required user. If no user is selected, the configuration will apply to all users in the clinic. * In the left panel, select **Medical Records.** * In the right panel, expand the **Medical Records Tabs** section. * Toggle on the **Treatment Plan View** switch to enable the tab. To disable it, toggle the switch off. Once configured, the **Treatment Plan** tab will be available (or hidden) in the **Medical Records** screen for the selected user(s). #### 10. How do I enable the Casesheet tab in Medical Records? Admin or authorized staff member can enable the **Casesheet** tab for users by following these steps: * Open the **Application Configuration** screen by navigating to **Home > Setup > Application Configuration.** * In the **Users** dropdown, select the required user. If no user is selected, the configuration will apply to all users in the clinic. * In the left panel, select **Medical Records**. * In the right panel, expand **Medical Records Tabs** section. * Toggle on the **Casesheet View** switch to enable the tab. * (Optional) To display the casesheet in the **Journey** tab, select the **Show In History** checkbox. Once configured, the **Casesheet** tab will be visible in the **Medical Records** screen for the selected user(s). #### 11. How can I view other doctors’ patient medical records without having edit access? By default, doctors have access only to their own patients in the **Doctor's Queue**. To allow a user to **view (read-only)** medical records created by other doctors, an admin or authorized staff member must configure the following settings: * Open the **Application Configuration** screen by navigating to **Home > Setup > Application Configuration.** * In the **Users** dropdown, select the required user. If no user is selected, the configuration will apply to all users in the clinic. * In the left panel, select **Visit Queue.** * In the right panel, expand the **Show All Doctors** section. * Enable the **Show All Doctors** toggle switch. Once this is enabled: * In the **Past Medical Records** screen, a **Show All Doctor Visits** checkbox will appear in the filter section. * When selected, the user will be able to **view** other doctors’ visit records in **read-only mode**. #### 12. How do I remove mandatory fields in the Dosage Info section when adding medicines in the Medication tab? Only an admin or authorized staff member with the appropriate access rights can modify the mandatory fields in the **Medication** tab. To make fields optional, follow these steps: * Open the **Application Configuration** screen by navigating to **Home > Setup > Application Configuration.** * In the **Users** dropdown, select the required user. If no user is selected, the configuration will apply to all users in the clinic. * In the left panel, select **Medical Records.** * In the right panel, expand the **Medication Tab** section. * Locate the **Medication Tab Mandatory Fields** setting and click on the **Edit** icon. * Remove the fields you want to make optional from the list. * Select the **Save** icon to apply the changes. The removed fields will no longer be required when adding medicines in the **Medication** tab. #### 13. What should I do if I get an alert saying another user is updating the information in the Medical Records screen? If you receive an alert stating that another user is updating the information and you cannot proceed with the patient in the **Medical Records** screen, it means the patient file is currently in use or was not properly closed by another user. You can resolve this issue in either of the following ways: * Ask the user listed in the alert (the **acquired user**) to reopen the patient file and click **Save** to release the lock. **Or** * An admin or authorized staff can manually release the lock: * Open the **Release Lock** (**Home > My Tasks > Release Lock)** screen. * Review the list of locked files, including details about the user and module. * Locate and select the checkbox next to the affected patient file. * Click **RELEASE LOCK**. Once the lock is released, other users will be able to access the patient file. #### 14. What are the different ways to capture vital values? **From the Medical Records screen:** * Open the **Medical Records** screen by navigating to **Home > Patient Queue > Medical Records**. * **SOAP tab**: In the **Diagnosis** tab, select the **Expand** icon in the **Patient Vitals** section to enter vitals. * **Patient Vitals button**: Select the **Patient Vitals** button in the right panel to open a slide-up pop-up and enter vital values. * **Pre Check tab**: Navigate to the **Pre Check** tab to enter vitals directly. **From the Scheduler:** * Open the **Scheduler** screen by navigating to **Home > Front Desk > Scheduler.** * Select the patient's appointment card to open the **Appointment Information** pop-up. * Select the **Pre Check** hyperlink to open the **Pre Check** pop-up. * Enter the patient's vital values and nurse notes, then select **Save**. If needed, you can add multiple entries. **From the Patient Queue:** * Open the **Patient Queue** screen by navigating to **Home > Front Desk > Patient Queue.** * Select the patient visit, then choose **More Actions > Pre Check**. The **Pre Check** pop-up opens. * Enter the patient's vitals and nurse notes, then select **Save**. Multiple entries can be added if required. #### 15. How to remove the mandatory symbol for Dental Procedures (SOAP tab) in Medical Records? Only an admin or authorized staff member has the access rights to change the settings. Follow the steps to change the setting: * Open the **Application Configuration** screen by navigating to **Home > Setup > Application Configuration**. * In the **Users** dropdown, select the required user. If no user is selected, the configuration will apply to all users in the clinic. * On the left-side section, click **Medical Records**. * In the right section, find the **Medical Records Soap Tabs Configurations**, navigate to **Dental Procedures**, and deselect the **Mandatory** checkbox. #### 16. How to create a template for individual SOAP tab? * Enter the required information in the relevant **SOAP** tab within the **Medical Records (Home > Medical Records > Current Medical Records)** screen. * Hover over the SOAP tab and click the **TEMPLATES** button that appears. * In the pop-up menu, you’ll see two options: * **Existing Templates**: Append to or overwrite an existing template. * **Create New Template**: Create a new custom template. * Enter a name in the **New Template** field. * To share the template with all users, check the **Share templates with all** box. * Click **SAVE**. The template will now appear under existing templates. * For future visits, you can use the same pop-up to reuse or update the template as needed. #### 17. What settings need to be checked if a user can't see the casesheet tab? Only an admin or authorized staff member has the access rights to update settings in the application. To update the details, please follow the steps below: * Open the **Application Configuration** screen by navigating to **Home > Setup > Application Configuration.** * In the **Users** dropdown menu, select the respective user. * On the left-side section, click **Medical Records**. * Search the **Casesheet** **tab** in the right-side section and enable the required switches. #### 18. How do I create a prescription template? You can create a prescription template either during a patient visit from the **Medical Records** screen or independently from the **Templates** screen. **To create a prescription template from Medical Records:** * Navigate to **Home > Patient Queue > Medical Records**. * In the **Medication** tab, add the required medicines to the prescription list. * Click the **Prescription Template** icon in the right panel. * In the Prescription Template pop-up, click **CREATE**. * Enter the following details in the new pop-up: * **Template Name**: Provide a name for the template. * **Remarks**: (Optional) Add any additional notes. * Click **SAVE** to add the template to the list. **To create a prescription template without a visit:** * Navigate to **Home > Templates > Prescription Template.** * Click the **+ (New)** icon to open the creation screen. * In the Prescription Template creation screen, enter the **Template Name**. * Use the **Search Medication** field to search and add a medicine. * Select the **Composition**, enter dosage details, and click **Save** to add the medicine to the list. * Repeat the steps to add additional medicines. * Once all medicines are added, click **SAVE** to create the template. #### 19. Why am I getting the error “Prescribe atleast one medicine” while posting eRx? This error typically occurs if: * No medicines have been added to the medication list, **or** * The **Payer ID** for the selected insurance is not configured correctly in the **Insurance Master**. To update the Payer ID: * Open the **Insurance Master (Home > Admin > Insurance > Insurance Master)** screen. * Locate and select the insurance to open its details. * In the **Claim PayerID** section: * Choose the appropriate **PostOffice Type** from the dropdown. * Enter the correct **Payer ID** in the **Claim PayerID** field. * Click **Save**. After updating the visit, retry posting the eRx. The error should no longer appear. #### 20. How do I unlock the Nurse Notes SOAP tab in Medical Records for a nurse user? Only an admin or authorized staff member can unlock the **Nurse Notes** – SOAP tab by updating the configuration settings. * Open the **Application Configuration** screen by navigating to **Home > Setup > Application Configuration**. * From the **Users** dropdown, select the relevant nurse user account. * In the left panel, select **Medical Records**, then expand **Medical Records SOAP Tabs Configurations** in the right panel. * Locate **Nurse Notes** and clear the **Read Only** checkbox. Now the **Nurse Notes** tab will be unlocked in **Medical Records** for the selected nurse user. #### 21. Why am I getting the error “Login failed for the user. Facility and Clinician Username and password are required” while posting eRx? Only an admin or authorized staff member can update the license information. This error shows up when the clinic or clinician license details are missing or incorrect in Unite EMR. **For Clinicians** * Open the **Users** screen by navigating to **Home > Admin > User Setup > Users.** * Use the **Search** field to locate the specific user. Click the **Edit** icon to open the user account. * Navigate to the **License & Credentials** tab. Use the **ADD LICENSE** button to update the details. * Click **SAVE** to save the details. **For Clinics** * Open the **Clinic** screen by navigating to **Home > Admin > Master Setup > Clinic**, select the clinic, and enter the **required license details**. * Click **SAVE** to save the details. *** --- # Agent Instructions: Querying This Documentation If you need additional information that is not directly available in this page, you can query the documentation dynamically by asking a question. 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