Consults & Clinical

The Clinical tab of a patient's file is where all of their clinical information, including consult notes, are stored.

Clinical details

The Clinical tab is where you can manage the clinical aspects of the patient's health record.

On the right hand side of the Clinical tab you will see the Adverse Reactions, Medications, Diagnoses and Past Procedures tables where these details can be stored. 

You can expand or hide each section to view its contents by clicking the drop down arrow just to the left of the table heading.

More detail is given below for each section.

Adverse Reactions

You can list any reactions or allergies that the patient has in this section.

To enable interaction checking please see our article on Drug & Allergy interaction checking. 

To add a new adverse reaction:

1. Click the + icon within the Adverse Reactions table.
2. The New Adverse Reaction window will open.
3. Enter the name of the agent (substance). Gentu will prompt you to select from a list of matching results, or you can enter your own.
4. Search for the manifestation (reaction). Select from the list or enter your own.
   
5. Select the reaction severity.
6. Enter any notes as needed.
   
7. Press Save.

The new adverse reaction will be added to the patient's Adverse Reactions table. 

After adding an adverse reaction, you may also wish to mark it so that it prints out on the theatre list if this patient is booked for surgery:

1. Hover your mouse over the adverse reaction in the Adverse Reactions list.
2. Click the flag icon that appears.  

Medications

The Medications table shows a list of all the patient's current, active medications and prescriptions.

You can quickly add a new medication to the table for record keeping purposes as follows:

1. Click the + icon within the Medications table.
2. The Add Medication section will open.
3. Search for the medication.
4. Select it from the results list.
5. Press Save.

 Please see the Prescribing article for detailed information on:

• adding medications for a patient
• creating and printing prescriptions
• inactivating/re-activating prescriptions

Diagnoses

This is where you can add any prior or current diagnoses which are relevant to the patient's care.

To add a new diagnosis:

1. Click the + icon within the Diagnoses table.
2. The New Diagnosis window will open.
3. Enter the diagnosis name. Gentu will present you a list of results to choose from, or you can enter your own.
   
4. Enter the onset date (if known) and the resolution date (if applicable).
5. If the condition is ongoing, tick Active.
6. Enter any notes as needed.
   
7. Press Save.

The new diagnosis will be added to the patient's Diagnoses table.

The Diagnoses table shows the patient's current conditions and their onset date.

Note that current, active diagnoses will be shown in red text.

Past Procedures

This is the place to add records about procedures this patient has had previously - for instance, before coming under your practice.

Add a new Past Procedure as follows:

1. Click the + icon within the Past Procedures table.
2. The New Past Procedure window will open.
3. Enter the procedure name. Gentu will present you with a list of results to choose from, or you can enter your own.
4. Enter the date the procedure was performed.
   
5. Add any notes as needed.
6. Press Save.

Consults

Consults allow you to keep records for each consultation you have with the patient.

The Consult window is divided into sections - Reason for encounter, History, Examination and Plan - to assist with streamlined and consistent record-keeping.

Add a consult

To add a consult within Gentu:

1. Open the patient's file (or their appointment).
2. Select Add > Consult Note.
3. Gentu will take you to the patient's Clinical file and load the New Consult window.
4. Fill in the required information.
5. Press Save.

Note: Did you know you can prescribe at the same time as adding Consult Note? Saving or printing a new medication or prescription will not reload the page or close the consult.

You will note that Gentu will automatically populate the date and time of the consult. You can edit the date and time manually if needed.

Edit or delete consults

If you need to edit or delete a consult, you can do so with the Open and Delete buttons (respectively) at the top of the Consult Note preview.

To delete a consult:

1. Select the Consult Note on the left.
2. Click Delete.
3. Confirm the deletion.

Alternatively you can delete a consult by finding it in the list, clicking the menu icon, and selecting Delete. 

To edit a consult:

1. Select the Consult Note on the left.
2. Click Open.
3. Make the desired changes.
4. Press Save.

If you cannot see the Edit and Delete buttons, it suggests that you do not have permission to access to these functions and will need to speak to the Administrator of your Gentu. 

Deleted consults

Deleted consults can be viewed or restored as needed.

To view deleted consults:

1. Open the patient's Clinical page.
2. Select the Consult Notes tab at the top of the list. 
3. Click the menu icon. 
4. Select Show deleted. 
   

The page will reload to show deleted Consult Notes in the list.

Note that enabling "Show deleted" will also show any previously deleted Procedures for the patient, when in the Procedures filter or the All filter.

Deleted Consult Notes are shown in greyed out text.

You can select a deleted Consult Note to view all its details.

To restore a consult:

1. With Show Deleted enabled (as per above), select the Consult Note from the list.
2. Click Restore.
   
3. The Consult Note will immediately be restored to its active state.

Alternatively you can restore a consult by selecting it in the list, clicking its 3 dots icon, and selecting Restore. 

Restrict consult notes

It is possible to lock consult notes so they are only visible to the user who created them.

Please see the Restrict Patient Records article for more information.

Reasons for encounter

When you create a consult, you can enter the Reason for Encounter - the patient's presenting problem. 

If you have a list of common presenting problems, you can record these within your Gentu's Settings.

This will then allow you to more easily choose a reason for encounter from the pre-populated list when clicking into the Reason for encounter field.

You can also begin typing into the Reason for encounter field, and Gentu will search your list for any matching results.

You can add Reasons for encounter within Settings > Reasons for encounter.

Alternatively you can simply freely type into the Reasons for encounter field when adding a new Consult Note.

Type in the reason for encounter, then press Enter to confirm.

You can add as many reasons for encounter as needed.

Attachments

If you prefer to handwrite your consult notes, you can easily upload your notes into the patient's clinical file. 

First, you will need to scan your handwritten notes onto your computer - this must be done outside of Gentu.

You can then add them to Gentu as follows:

1. Access the patient's file.
2. Select Add > Attachment.
3. Click Choose File.
4. Browse to the file on your computer and select it.
5. If desired, use the File Name field to rename the file.
6. From the Category drop down menu, select Consult Note.
   
7. Press Upload.

By selecting the Consult Note category, Gentu will upload the attachment as a Consult Note record, applying all the user role permissions for Consult Notes to it. This is useful if you have set permissions to exclude certain user roles from viewing Clinical or Consult Note information.

The same applies, respectively, to any Category that you select for the Attachment when uploading it.

FAQ

> Does dictation software work with Gentu?

Gentu does presently work with Dragon Medical Dictation, and we have a projected vision to have other VRS solutions implemented with Gentu in the future. 

If you're interested in Dragon, we suggest you contact voicerecognition.com.au, the Australian resellers for Dragon software.

> Can I stop certain users from viewing clinical information?

Yes, the ability to view, edit and add clinical information can be managed from the User Roles within Settings > User Roles.

You can also lock clinical records - please see our Restrict Patient Records article for more information.

> Can I use Macros in Gentu to help with writing my consult notes?

Gentu does not currently have a built in option for Macros. However you can download extensions for your browser to allow this functionality - one example is AutoTextExpander for Chrome.

This will allow you to create your own macros and have them auto-expand into text when typing in Gentu.