A Medical Record is a key compontent of a patient record that contains medical or diagnostic information. The medical records for a patient are listed under the Medical Records tab of the Patient Information screen. Most records can be opened from that list in order to view the information contained within the record, though some records, such as demographic records, will appear in the list but cannot be opened. Records that cannot be opened are shown in the list with a lighter gray font color, while the rest are shown with a black font color. If a record has been deleted or canceled, it will be listed with a line through it.

In VMIS, there are different types, or categories, of medical records. Categories help identify what information is contained within a record and are used to organize records. In addition to categories, medical records are organized by which admission, or visit, they were created under.

(close up picture of record list highlighting categories and visits)

Medical records are created from the Create New Medical Record screen, which is accessible through the Document button near the top of the Patient Information screen.

NOTE: This button is only enabled when a patient is loaded into the Patient Information screen

The Create New Medical Record screen lists all of the different types of records that can be created, though some of these options may not always be selectable. Which options are enabled is dependent upon the rights assigned to the currently logged on user and if the patient is currently pre-admitted or admitted to the Hospital. Selecting the appropriate record type and clicking the “OK” button will open a new screen specific to the selected type.

(picture of MR Add screen, specifically highlighting the record options, not request options)

In VMIS, a medical record is marked complete by finalizing the record. Once a record is finalized it can no longer be edited, which helps maintain the integrity of information within that record. Some types of records allow adding notes as addenda if additional information needs to be added after they were finalized. The ability to finalize a record is limited to only users who have been granted finalization rights. A record can be finalized by opening the record and clicking the Finalize button.

(picture of the top portion of a medical record, highlighting the finalize button)

NOTE: If a record is accidentally finalized before it is complete, the Medical Records office can assist with un-finalizing records.