OpenEMR: Review of Systems with Integrated Text Box for Clinical Notes

[MeghaMoncy]

One important feature of the OpenEMR is the Review of Systems (ROS), which is a standardized set of questions that healthcare providers ask patients to assess their overall health status. However, the current version of OpenEMR limits the ROS to Yes, No, and N/A options for each system, making it challenging for providers to accurately document patient responses and provide detailed information in the clinical notes of the encounter. Moreover, providers have to enter clinical notes separately, which is an additional step and can be time-consuming.

Steps to Replicate the Issue:

• Login to the OpenEMR.

• Click on "Finder" and select a patient to work on.
• The Medical Record Dashboard of the patient will open up.
• Click on the “+” near the "Select Encounter" tab on the top of the patient's dashboard to create a new encounter or elect from the previously entered ones.

• In case of new encounter, enter all relevant visit details of that encounter, and save the changes.
• Encounter for the patient will be created and the patient summary will be displayed.
• Click on the “Clinical” tab and select Review of Systems from the drop-down menu.

• A long list of Systems opens up with Yes, No, and N/A options for each system. It does not provide any text box for explaining the issue further.

By integrating a text box for each system in the ROS, providers would be able to more accurately document patient responses and add relevant notes simultaneously. This would save time for the provider and improve the quality of the patient's care.