Fomu ya SOAP ya Record Electronic Health

Mauthenga azachipatala (EHR) amathandiza ogwira ntchito zachipatala kuti asamalire bwino chisamaliro cha odwala pogwiritsa ntchito zolemba, kusungirako, kugwiritsa ntchito ndi kugawa zolemba za odwala. Pambuyo pa mapulogalamu a zamagetsi asanatulukire, madokotala ankagwiritsa ntchito mawonekedwe a SOAP monga njira yolondola yolemba.

1 -

Electronic Health Record

Mbiri yachipatala ndi zolemba zovomerezeka za mbiri ya wodwalayo komanso chisamaliro chake. Nthawi zambiri imakhala ndi uthenga wathanzi wotetezedwa wa wodwala (PHI) womwe umaphatikizapo chidziwitso chodziwitsa, mbiri yaumoyo, zofufuza zachipatala ndizodziwitsa. Mbiri yachipatala yowonjezera ikuphatikizapo:

• Chiwerengero cha odwala
• Zambiri zachuma
• Maumboni ndi maulamuliro
• Mbiri ya chithandizo
• Kupita patsogolo
• Dokotala ndi malamulo
• Kufufuza
• Lab ilipoti
• Malipoti a Radiology
• Malingaliro achikulire
• Mndandanda wa mankhwala
• HIPAA Zindikirani Zomwe Mumachita Zachinsinsi

Chigawo cha zachipatala chomwe chimagwiritsa ntchito mawonekedwe a SOAP ndicho gawo la Mapendekiti. Phokoso limayimira Wophunzira, Cholinga, Kuunika, Ndondomeko. Mpangidwe wa SOAP ukhoza kugwiritsidwabe ntchito ndi mbiri ya umoyo wa magetsi monga momwe amagwiritsidwira ntchito ndi zolemba zamankhwala.

2 -

S Ndilo Wodzipereka

S Ndilo Wodzipereka

Mfundo zogwiritsa ntchito zimakhudza malingaliro ndi malingaliro a wodwalayo za momwe amamuonera momwe alili dongosolo la thanzi lawo. Mfundozi ziyenera kulembedwa pogwiritsa ntchito mayankho a wodwalayo ku mafunso okhudzana ndi chithandizo cha mankhwala kapena matenda omwe alipo.

Chidziwitso chotsatira chimaphatikizapo:

• Mbiri yakale ya zamankhwala
• Mbiri ya matenda omwe alipo
• Ndemanga za zizindikiro
• Mbiri ya anthu
• Mbiri ya banja

3 -

O Ndi Cholinga

O Ndi Cholinga

Zolinga zofunikira zokhudzana ndi zizindikiro zofunika za wodwalayo, zigawo zonse za kufufuza thupi, ndi zotsatira za mabala, X-rays, ndi mayesero ena omwe amachitikira poyendera wodwalayo.

Zolinga zolinga zikuphatikizapo:

• Kutentha, kuthamanga kwa magazi, kuthamanga, ndi kupuma
• Kuwonekera kwakukulu
• Ziwalo zenizeni, mapeto, ndi minofu
• Mavuto a maganizo ndi aumoyo
• Zina zambiri zokhudzana ndi zapadera

4 -

A ndi Yoyesera

A ndi Yoyesera

Ndondomeko zowunika zimagwirizanitsa mfundo zomwe zimapangitsa kuti wodwala akhale ndi thanzi labwino, moyo wake, kapena matenda. Kuwunika kumaphatikizapo kufotokoza mwachidule chitukuko cha wodwalayo kuyambira paulendo womaliza kuchokera kuchiwonetsero cha wodwala.

Zomwe akuyesa zikuphatikizapo:

• Zizindikiro zazikulu ndi matenda
• Odwala akupita patsogolo
• Kusiyanitsa mitundu
• Kulongosola kwakukulu kwa wodwala ndi chikhalidwe chafotokozedwa

5 -

P Ndizokonzekera

P Ndizokonzekera

Konzani ndondomeko zokhudzana ndi zochita zanu chifukwa cha ndondomeko zowunika. Ndondomekoyi imaphatikizapo chilichonse chomwe dokotala akukonzekera kuchita kapena kuwuza wodwalayo kuti achite pofuna kuchiza wodwala kapena kuthetsa nkhawa zawo. Izi ziphatikizapo zolembedwa za malamulo a dokotala kwa mautumiki osiyanasiyana operekedwa kwa wodwalayo.

Pulani ndondomeko ikuphatikiza:

• Mayeso a Lababu
• Ntchito zamagetsi
• Ndondomeko
• Chidziwitso cholozera
• Malemba kapena mankhwala OTC
• Maphunziro Oleza Mtima
• Kuyesedwa kwina

6 -

Kugwiritsira ntchito SOAP kuti Pewani Zolakwa Zamankhwala

Pali zifukwa zambiri zomwe zolakwika zachipatala zimapezeka mu ofesi ya zamankhwala. Zambiri zimakhala ndi dongosolo kapena ziyenera kukhala ndi dongosolo loletsa zolakwika kuti zisadzachitike koma kulankhulana bwino ndi nambala yoyamba yomwe zolakwika zachipatala zimachitika pamene dongosolo liripo. Ogwira ntchito ku ofesi ya zamankhwala, anamwino, ndi madokotala akufunikira kumvetsa kufunika kwa zolemba zomwe ndi njira yabwino yolumikizira zochitika za odwala.

Zolemba sizimangophatikizapo zizindikiro, matenda, matenda, mankhwala, komanso mankhwala komanso mavuto komanso zoopsa zaumoyo ndi chitetezo. Zonsezi zingakhale zothandiza popewera zolakwika zachipatala. Kumbukirani kulembera zolakwika zomwe munalakwitsa kale komanso nkhawa za wodwalayo. Si zolakwika zonse zomwe zingapeweke koma ngati zolembedwazo zikulembedwa molondola, akatswiri azaumoyo amatha kuzindikira ndi kukonza zolakwika asanakhalepo zovuta zachipatala.

Mauthenga osakwanira kapena osakwanira odwala komanso kusokoneza mauthenga angakhale ndi zotsatira zoopsa ku ofesi ya zachipatala ndi odwala ake. Chidziŵitso chofunika kwambiri chomwe sichidziwitsidwe chingakhale ndi zotsatira zoopsa. Ngakhale zovuta zina sizingapeŵeke, kuyankhulana koyenera kungabweretse zotsatira zabwino kwa odwala komanso kupambana kwathunthu kwa ofesi ya zamankhwala.