Zeiss 3000 - Edit Clinical Notes; Categorize Patient Records

Data Management
Stratus OCT User Manual PN 2660021134133 A
7-8
Edit Clinical Notes
While clinical notes may be of a general nature regarding a patient, in Stratus OCT, clinical
notes pertain to specific visits and exams. You must edit (or add) clinical notes in either the
E
XAM RECORD WINDOW or the VISIT RECORD WINDOW. To do so, follow these steps:
1. In the M
AIN WINDOW, select the desired patient and then select either a visit record or
exam record.
• If you selected a visit, select Vi
sit from the Patient menu (click Patient > Visit) to
open the V
ISIT RECORD WINDOW.
• If you selected an exam, then select Exam from the Patient menu (click Patient >
Exam) to open the E
XAM RECORD WINDOW.
2. In either window, click the
Edit Current Record button to activate the fields for
editing.
3. Add or edit the desired exam/visit notes or
remarks. After making the desired
changes, click the
Save Record button.
• To discard the changes befor
e saving, click the Undo Changes button. You must
confirm your choice in the C
ONFIRM dialog box.
Categorize Patient Records
You can create your own categories and place patient records in them. This enables you to
search for patient records by category during data transfer operations such as import,
export, archive and retrieve. See Advanced Search on page 7-2 for more information.

Note: Category names are case-sensitive, which affects their uniqueness in
searching for them. For example, “control group” and “Control Group” would be
treated as different categories.
The search function in the M
AIN WINDOW enables you to find patient records by name or
patient ID, but is not as useful when searching for patients by group criteria, which you
may want to do during data transfer operations. For example, in larger institutions that
have thousands of patient records, creating categories enables you to subdivide a very
large database. This reduces search time and generally makes managing patient records
easier. As another example, you may create categories to contain patients who participate
in a study. The Stratus OCT offers special features for use in categories designated for
clinical trials.
In general, the advantage of the categories function is that it provides you the ability to
cr
eate groups of your own design for any reason, and to directly control their membership.
All other search criteria arise from objective data (with the exception of diagnoses that you
create and assign, albeit based on exam data).