SANDI - Exams & Forms: Medical Record Documentation (Visit Report, Image Uploads, SOAP Notes, etc.)

When a patient is registered in SANDI, a report titled “Visit Report” will automatically be created. A visit report should be created for all patient visits including suture removal, bandage changes, and visits where the patient dies. The only exceptions is lab work only (where the patient is not seen), and outpatient imaging. The patient visit report is printed for the owner at the time of discharge and is sent to the rDVM. Typically a Visit Report is started by a student and then an Intern or Resident will finish the report. Finally a faculty or Resident will verify the report.

Examination Medical Record Documentation Overview

1. Bring up the proper Client/Patient in the Patient’s Dashboard and select the arrow next to Exams/Forms.

SANDI-ExamsFormsForSend.jpg

2. The Exams/Forms screen will display all patient history. 

SANDI-ExamsFormsSendActions.jpg

Selecting an existing Draft Report for Completion

1. Select Exams & Forms from the Patient Dashboard by selecting the arrow.

forms

2. Select the Edit button next to the proper visit. (Pencil Icon edit)

sel temp

3. At Template Selection expand your service and select all the templates you would like to include on your report. Those selected will appear in the right hand column.

serv temp

4. Select Add Template(s)

temp sel

5. You many now begin completing your template. 

Notes:

6. Once your report is complete you may:

Adding a Report

1. Select Exams & Forms from the Patient Dashboard by selecting the arrow.

Exams&FormsBox

2. Select Add (Blue button in upper left corner of the Exams/Forms box.)

3. Select the exam for which you are adding the report

4. Select Visit Report and select Submit

5. At Template Selection expand your service and select all the templates you would like to include on your report.

serv temp

6. Select Add Template(s)

temp sel

7. You many now begin completing your template. 

Notes:

8. Once your report is complete you may:

 SANDI - Send Reports to Clients, rDVM, etc.