Introduction

QCare PACU is the patient record for recovery and post anaesthetic care units.

Problem list

The window of the problem list shows the patient's past record ; the data that were entered during a previous stay. He can complete the present status of the patient by means of diagnostics/problems and comments. Diagnostics are based on the ICD9 or 10 classification and will be made usable through the options of QCare PACU : search function, own classification, own terminology for diagnostics, search frequently used codes or create new codes).

Treatment

The treatment planning is the hinge between the activities of physicians and nurses: here new orders are made, changed, extended and stopped. Based on these orders, QCare PACU automatically generates a nursing planning: a visual interface based on a time line on which is indicated very clearly when orders must be carried out, with detailed dosages, flows, ways of administration, samples to be taken and additional information.
The nurses indicate when an order was carried out and the reasons for which they would have possibly deviated from an order. By indicating that a prescription was executed, QCare PACU can send the necessary consumption overviews to the invoicing departments, calculate balances and generate statistics.
With this timeline QCare PACU offers an overview of monitors, respirators, laboratories, scores, functions or observations.

Results

Resultviewers give access to latest lab- and monitoring results. You can ask for history views or graphs. All results stay available on-line. At reception of new results or in case of anomalies, warnings can be given (in color, with sound, dialog boxes or a combination).

Decision Support

The Decision Support Server examines the patient records constantly on the basis of self made or imported rules. Depending on the results, the Decision Support Server starts the necessary (defined) actions.

Some examples:

• Warnings on interactions between drugs or between drugs and diagnostics or results.
• Logging of abnormal results or series of results.
• Signalisation for clinical research
• Quality control on filling out a minimal data set.
• Automatic calculation on the receipt of new results.

External reporting

Letters and reports (entry, discharge, current status, ...) are created using templates. A template consists of standard text, combined with links to certain data from the file : when making a new report, those links are filled out with data coming from the current medical record: no additional typing is needed.

Internal reporting

In order to keep an overview of the mass of data (and because a monitor stays limited in size), C³ created the summary. The summary contains important data or free text. The structure, the layout of the summary is defined upon users' specifications.
A summary can be updated at any moment and from no matter which module. Every day new results are added to and deleted from the summary. When having a look at the summary, you can also go back in time to read the important remarks on that day, week or month. The summaries are not limited in length or number, in this way every user can make his own separate summary.

Knowledge base

Users have permanent access to a central knowledge base sharing all kinds of information, using a context sensitive search engine. Internet pages can also be accessed in this knowledge base.