Basic Inpatient forms

Hi all,

I am an ophthalmologist trying to implement OpenEMR in a fledgling practice.

Our Outpatient is finding the implementation quite streamlined.

We have recently completed our first inpatient procedure as well.
we don’t have the budget to purchase commercial modules.

however i was not able to find any layout or procedure to admit the patient , enter the procedure notes, and discharge the patient .
we had to give a ‘made-up’ bill [valid , but constructed on MS word.] because we didn’t understand how to do it.

diagnosis was : left eye : Retinal detachment with single break.
the procedure was left eye : 25 gauge pars plana vitrectomy with membrane peeling with PFCL assisted subretinal fluid drainage with fluid air exchange with c3f8 gas injection under la.

the notes have to be very detailed, and also there is a post op follow up which can somehow be maintained in the outpatient form itself. but inpatient details such as anesthesia administered, notes, surgical notes , post op advise all of this is missing.

can anyone please guide us ?

Hi @Dr_Aditya_Barigali ,
Open-emr comes with some forms that you would need to activate . Please look at Admin → Forms → Forms Administration to see if any form would work for you.

There is also Layout Based Visit Forms that you can customized based on your unique need please look at a step by step on how to create a form
https://www.open-emr.org/wiki/index.php/LBV_Forms

There are soem good videos here:

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You can also create and import LHC-Forms or search LOINC for Questionnaires/Forms that may be appropriate.

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This is where my expertise is insufficient.
I’m truly lost in the configuration.

also i wasn’t able to find nation notes module. where is it ? because i have an ODT file template for both surgical notes and discharge summary. just want to be able to upload it , fill it and print it.

any help is deeply appreciated.

Nation Notes is only available in an LBF.

Hello @Dr_Aditya_Barigali

OpenEMR is optimized for outpatient practices though some work has been done on adapting it for inpatient work. You might check the forum thread on that topic to see if anybody has useful ideas:

As mentioned, Nation Notes is a sub-set of the Layout Based Forms feature. You can read about them in the OpenEMR wiki here:
https://www.open-emr.org/wiki/index.php/Nation_Notes
and:
https://www.open-emr.org/wiki/index.php/Sample_NationNotes_Form

Search for mentions of it (or any other topic) in other wiki pages using the search tool at the bottom of every wiki page:

Here is a link to using the questionnaires feature mentioned by the OP earlier in this post:
https://www.open-emr.org/wiki/index.php/OpenEMR_Questionnaire_–_Conclusion

Another capability you might want to explore is the document templates, which appears compatible with your aims: you might be able to transform your ODT templates for use in the EMR.
https://www.open-emr.org/wiki/index.php/Patient_Portal_Document_Templates

Good luck, and feel free to come back here with any more questions you may develop about all this.
Best- Harley

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