Tsarin SOAP na Lissafin Kiwon Lafiya na Electronic

Rubutun lafiyar lantarki (EHR) yana ba masu kula da kiwon lafiya damar kula da kulawa ta haƙuri ta hanyar takardun, ajiya, amfani da rabawa na rubutun masu haƙuri. Kafin tashiwar bayanan lafiyar lantarki, likitoci sunyi amfani da tsarin SOAP a matsayin hanya mai kyau na takardun.

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Bayanan Lafiya na Lissafi

Bayanan likitaccen takardun shaida ne game da tarihin likita da kulawa. Yawancin lokaci ya ƙunshi bayanin lafiyar lafiyar mai kula da lafiyar (PHI) wanda ya hada da bayanan ganewa, tarihin kiwon lafiya, binciken binciken likita da bayanin lissafin kuɗi. Bayanan likita na al'ada sun hada da:

• Masarrahu masu haƙuri
• Bayanan kudi
• Dokar izini da izini
• Tarihin jiyya
• Matakan cigaba
• Dokokin likita da umarnin
• Saduwa
• Labaran Lab
• Rahoton radiyo
• Bayanan kulawa
• Jerin magani
• HIPAA Bayanin Tsare Sirri

Sashen ɓangaren aikin likita da ke amfani da tsarin SOAP shine Sashen bayanin kulawa na Progress. SOAP yana nufin Tsarin, Manufar, Bincike, Shirin. Tsarin SOAP za'a iya amfani dashi tare da rikodin lafiyar lantarki kamar yadda ake amfani dasu tare da bayanan likita.

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S Yana da Ginin

S Yana da Ginin

Rubutun bayanan da suka shafi ra'ayoyin marasa lafiya da kuma jin dadi game da yadda yake ganin tsarin lafiyarsu ko tsarin kulawa. Wannan bayanin ya kamata a rubuce bisa la'akari da amsa ga masu haƙuri akan tambayoyi game da tsare-tsaren magani ko kuma cututtuka na yanzu.

Bayanin bayani ya haɗa da:

• Tarihin kiwon lafiya na baya
• Tarihin rashin lafiya yanzu
• Review na bayyanar cututtuka
• Tarihin zamantakewa
• Tarihin iyali

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O Yana Ga Manufar

O Yana Ga Manufar

Manufofin bayanai sun danganci alamun alamun masu haƙuri, dukkanin kayan binciken jiki, da sakamakon labs, radiyo X, da sauran gwaje-gwajen da aka yi a lokacin ziyarar.

Manufar bayani shine:

• Temperatuur, saukar jini, bugun jini, da kuma numfashi
• Janar bayyanar
• Gabobin cikin gida, tsauraran matakai, da kuma yanayin ƙwayoyin cuta
• Yanayi marasa lafiya da cututtuka
• Sauran bayanan da suka dogara da sana'a

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A A Ga Bincike

A A Ga Bincike

Bayanan ƙididdiga na ƙarfafa bayanan ra'ayi da haƙiƙa wanda zai haifar da yanayin kiwon lafiyar mutum, salon rayuwa, ko ganewar asali. Wannan kima ya hada da cikakken bayani game da ci gaba na mai ci gaba tun lokacin ziyarar karshe daga likitan likitan.

Bayanin binciken ya hada da:

• Babban bayyanar cututtuka da ganewar asali
• Hanyar ciwo
• Bambanci daban-daban
• Bayani na ainihi game da haƙuri da yanayin da aka gabatar

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P ne don Shirin

P ne don Shirin

Shirye-shiryen tsare-tsaren sun danganci aikin aiki saboda sakamakon kima. Bayanin shirin ya haɗa da duk abin da likita ke shirin yi ko ya umurci mai haƙuri ya yi domin ya kula da marasa lafiya ko magance damuwa. Wannan zai hada da takardun likitan likita don ayyuka masu yawa da aka ba wa marasa lafiya.

Bayanin shirin ya hada da:

• Labar gwaji
• Ayyukan radiyo
• Hanyar
• Bayar da bayanin
• Bayanan bayani ko magunguna na OTC
• Ilimi na haƙuri
• Sauran gwaji

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Yin amfani da SOAP don hana ƙwayoyin lafiya

Akwai dalilai da yawa da ya sa kurakuran lafiya ke faruwa a ofishin likita. Mafi yawancin ayyuka suna da tsarin ko suna da tsarin don hana kurakurai daga abin da ke faruwa amma sadarwa mai talauci ita ce dalili na lamba 1 cewa ƙwayoyin lafiya suna faruwa yayin da tsarin ya kasance. Ma'aikatan kiwon lafiya, ma'aikatan jinya, da likitoci sunyi bukatar fahimtar muhimmancin takardun shaida wanda shine hanya mafi kyau don sadarwa abubuwan da suka faru.

Takaddun shaida ba kawai ya haɗa da alamun cututtuka, ganewar asali, kulawa, magani, da magani amma har matsalolin da hadari ga lafiyar lafiya da aminci zasu iya zama tasiri a hana ƙwayar likita. Ka tuna ka rubuta takardu kafin kuskure da ma damuwar damuwa. Ba dukkan kurakurai ba zasu yiwu bane amma idan an rubuta bayanai da kyau, masu sana'a na kiwon lafiya sun iya ganewa da gyara kuskure kafin wani taron likita ya faru.

Magance marasa lafiya ko rikitarwa marasa daidaito na iya haifar da mummunar sakamako ga ofishin likita da marasa lafiya. Ɗaya daga cikin mahimman bayani game da bayanai wanda ba'a bayyanawa ba zai iya samun sakamako mai banƙyama. Ko da yake wasu matsala ba za a iya shakku ba, sadarwa mai kyau zai iya haifar da kyakkyawan sakamako ga marasa lafiya da nasarar nasarar ofishin likita.