In this tutorial, you will learn about Adding and Editing Patient Information

View the tutorial video.

To add a new patient you will need to use the insert icon  .  Once the patient has been added to your database, you will have access to edit with the edit icon.

 



Last Name, First Name
Type the last name of the patient first, because the program sorts and lists patient names alphabetically. Then type the patient’s first name or initials and press Enter. The patient’s name can have characters and spaces.
Make sure all patient names are entered in the same format, with commas, spaces, and middle initials in the same place. If you vary the style from patient to patient, it can affect the order in which names are listed in Browse Windows and cause the data to appear unorganized.
Example: JOHNSON, Christopher A.


A couple of default values are pre-filled, Gestational age in weeks and Sex.


Physician
This field can be used to identify the referring physician, attending physician, admitting physician, or whomever your unit has decided should be listed. This field can simply be left blank simply. Because patients can be indexed and selected by physician, it is helpful to enter a name here.

You can choose from the pre-defined Physician pick list or add a completely new entry.  Some NICUs will decide to work with Physicians names, others will make the decision to work with teams.  Both methods are right.

 

 
By clicking over   , you will have access to the Physician pick list window selection.

 


 

By clicking the  Add new physician icon  ,  you will have access to a new window to create a new physician entry:

 

The name of the physician should be entered last name first.  When the entry is accepted, this new name will become available in the previous pick list.


Note:  Physicians may be pre-entered from the Configuration tab or from that access link whenever required from the patient edit window.


Sex:  choose Male or Female from the down arrow pick list.
 
Date of birth:  The computer system date is automatically displayed in the Birth Date field because most initial admissions occur on the date of birth/current date. You can change to a different date using the Date Editing Commands, but remember that the Birth Date must be on or before the Admit Date.  You may select a date from the calendar component.

Birth weight:  Enter the birth weight in grams, making sure to enter the weight expressed correctly. For example, enter a birth weight of 1000 g as 1000, not 1.0. The birth weight is critical throughout the program because it is required for the percentage change in weight from birth, change in weight from yesterday at age 1 day, and nutrient intake per kg on the infant’s birth date.  You may directly enter a weight or use the spin edit arrows  .

You can also enter a weight under 400 grams. In this case, when closing the Window, you will be prompted to confirm that the weight is correct.
 


Note:  the 400 grams value is a parameter from Configuration  System manager
 


Gest age (week): you may enter your test results directly or use the spin edit arrows  .  This is the number of gestational weeks.  This number must be greater or equal to zero.

Classification:  non editable field, generated from the weight gestational chart used to determine the appropriate classification, SGA, AGA, LGA.

NEONOVA automatically classifies the infant, based on birth weight and gestational age defined in Configure, as follows:
SGA — Small for Gestational Age
AGA — Appropriate for Gestational Age
LGA — Large for Gestational Age.

The word “Classification” followed by one of the above abbreviations appears below the Gest Age field. Classification is determined from the Weight-Gestational Age Values Screen in Configure. Gestational ages below and above the values defined in Configure are permitted, but no classification will be made for these values.

I M P O R T A N T:  make sure classification is properly configured.  If no Weight Gestational curves are used for classification, when creating/editing a patient, you will get a warning message and the resultant classification will be N/A.

Here is a sample extract from Configuration   Weight Age Gest tab.

 


Patient id:  Patient reference number used to locate patient information.  This number must be unique in your database.  The infant’s ID consist of numbers, letters, or a combination of numbers and letters.  This ID refers to the internal file number. After you have typed the ID, carefully proofread what you have typed.  You are required to enter an ID for each patient.
Example: A293-43-B78


Apgar tests results:    Three Apgar Scores can be entered. Type the 1-minute Apgar Score and press Enter. Next, enter the 5-minute score and the 10-minute score, pressing Tab after each value. If an Apgar Score is not available, press Tab to leave the space blank. A blank will not be interpreted as a zero value.

You may enter directly your test results or use the spin edit arrows  .   Valid range value is 0 to 10.


From the patient creation, when pressing  , the patient is added to the database and the Neonova returns to the Main Patient form.

 

The next section describes the  option.

 




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