Generation of Inpatient Diagnosis Card - hmislk/hmis GitHub Wiki

A Diagnosis Card is a clinical document that summarizes all patient-related medical information recorded from admission to discharge. It includes all relevant medical information such as history, diagnoses, treatments, vital signs, clinical notes, and discharge medications

Note: This document includes only clinical data and does not include financial data such as invoices or final bills.

This feature was originally requested by:

• Roseth Hospital
• Ruhuna Hospital

The goal is to provide a structured and complete clinical summary of a patient’s hospital stay.

To generate a Diagnosis Card, the following data must be recorded:

• Admission-related Data

  • Data recorded when admitting a patient (BHT No: RHD/Normal/Ward 27)

• Clinical Data of the patient

  • Patient history (Medical Conditions, Medications, Surgical Conditions, Allergies)
  • Clinical notes
  • Ward Medications
  • Discharge Medications
  • Diagnoses
  • Procedures

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Navigate to: Inward → Search → Admission → Select an active (non-discharged) admission → Inpatient Dashboard (Bed Icon)

• All clinical data must be recorded before generating the Diagnosis Card.

Path: Inpatient Dashboard → Clinical Data → Patient History

• This section records long-term and patient-specific medical information, not details specific to the current admission.

Example:

• Fever (current issue) → ❌ Not recorded here
• Hypertension → ✅ Recorded here

• This tab includes the basic patient identification and personal details.

• Types of Data

  1. Permanent Data
     • Rarely changes
     • Example: Date of Birth (DOB)
  2. Semi-Permanent Data
     • May change occasionally
     • Examples:
       • Name
       • Gender
       • Address

⚙️ Note: These fields can be configured via application settings based on hospital requirements.

• This tab includes long-term or chronic conditions of the patient.

• Examples:

  • Hypertension (High Blood Pressure)
  • Diabetes Mellitus
  • Bronchial Asthma
  • Heart Disease

• These belong to the Electronic Medical Records (EMR)

👉 See: How to Add Medical Conditions

• To records the long-term medications taken by the patient.

❗ Medications prescribed for the current admission are NOT included here.

Fields:

• Medicine Name
• Dose (e.g., 5 / 10 / 25 / 50)
• Strength Unit (mg, tablet, etc.)
• Frequency (once/twice/thrice)
• Duration (1 week/ 2 weeks)

• To record previous surgeries or procedures undergone by the patient.

👉 See: How to Add Surgical Conditions(Procedures)

• To record any allergies that patient may have:

  • Drug allergies
  • Food allergies
  • Environmental allergies

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Path: Inpatient Dashboard → Clinical Data → Clinical Notes

• If it says, you don't have privileges:
  1. Assign required privileges to the user for the relevant department
  2. Logout and login again

• Clinical Notes capture doctor/consultant observations during patient visits.
• Typically recorded:
  • Morning rounds
  • Evening visits (if applicable)

✅ These notes are essential for generating the Diagnosis Card.

• Click “+ New Clinical Assignment” and fill in:

  1. Complaints & History

  2. Vital Signs

     • Weight
     • Height
     • BMI -Temperature
     • Blood Pressure (BP) - Normal range: 80–120 mmHg
     • Pulse Rate (PR) - Normal range: 72–86 /min
     • SpO₂ (Oxygen Saturation)
       • Measures oxygen level in blood
       • Normal: 95–100%
       • Below 90%: Requires medical attention
     • Respiratory Rate (RR) - Normal range: 16–20 /min

  3. Diagnoses

  4. Procedures

  5. Plan of Action

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Path: Inpatient Dashboard → Clinical Data → Ward Medications

• Records all medications administered during the hospital stay

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Path: Inpatient Dashboard → Clinical Data → Medicine Timeline

• Displays chronological medication history

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Path: Inpatient Dashboard → Clinical Data → Discharge Medications

• To records medications prescribed at the time of discharge

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Path: Inpatient Dashboard → Clinical Data → Diagnosis Card

• Now let’s see how to generate the Diagnosis Card for the above patient with the added records.

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Navigate to: EMR (🩺Icon) → Settings → Documents → Add New Document Template

• Enter template name
• Select template type - InpatientDiagnosisCard/Prescription/Medical Certificate/etc.
• Use placeholders listed under "Available Placeholders"
  • These will be dynamically replaced with actual data
• Optionally:
  • Use AI tools to generate template content using placeholders
• Paste into :Template Content" box
• Click Save Template

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Navigate to: Inpatient Dashboard → Clinical Data → Diagnosis Card

• Select template from drop-down
• Click on "Generate"
• Click "Edit" if changes are needed
• Click "Save"

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• Click on “Generate with AI”
• System auto-generates the Diagnosis Card using available data
• Click on "Edit" if required to make changes on the generated content
• Save the final version after modifications