Patients: finding, registering and the record

Finding a patient

Patient search. Type a name, an identity number or a telephone number. Results rank by how well they match, not alphabetically.

Partial names work. "siti rah" finds Siti binti Rahman.
Identity numbers work with or without the dashes.
Telephone numbers work in any format the patient might have given.
Searching is not recorded in the audit log. Opening a record is.

If the search finds nothing and the main PC cannot be reached, Klinira says so rather than showing an empty list. An empty list would read as "this patient is not registered", and the counter would register them a second time.

Registering a new patient

Registration. Tap the MyKad reader if you have one; otherwise type. The duplicate check runs by itself as you leave each of the three fields that identify somebody.

1Tap the MyKad on the reader, if the clinic has one. Name, identity number, date of birth, gender and address fill themselves in.
2Otherwise type the name, the identity number and the telephone. A foreign patient, a child with no card and a clinic with no reader all take this path.
3Klinira checks for a possible duplicate as you move off each of those three fields. If it finds one, it shows you the existing record and asks.
4Record citizenship. It decides how service tax is treated on the bill, so it is asked at the counter rather than reconstructed at the payment desk on a busy morning.
5Save. The patient number is allocated by the main PC.

Two people in one household often share a telephone number, and a mother and a son can look like the same person to a computer. Klinira never picks a match for you — it shows what it found and waits.

The patient record

The patient profile. Allergies are at the top, never inside a tab and never collapsed. The visit history runs down the middle; contact, panel and rate are on the right.

Allergies are always visible. An allergy behind a tab is an allergy the doctor did not see.
Long-term conditions and current medicines sit beside them, so the clinical picture is one glance.
Editing details takes a lock, so two people cannot edit the same record at once. The lock is taken when you press Edit, not when you open the screen.

Putting a patient on a staff or family rate

1Open the patient's record.
2On the Rate card at the right, choose the price list.
3Press Change rate.

It prices bills raised from now on. Bills already raised do not move. To take somebody back off a staff rate, choose Standard prices — it is an entry in the same list.

Panel cards

A patient's panel card lives on their record, not in somebody's memory at the counter. Add it once — the panel, the card number, and the date the card runs to — and every bill afterwards knows which panel is paying without being told again.

1On the Panel cards card at the right, press Add.
2Choose the panel, type the card number, and put in the date the card is valid to.
3Save. Remove takes a card off when a patient changes employer.

Citizenship, and why it is a money question

Service tax applies to private healthcare given to somebody who is not a Malaysian citizen, and does not apply to a Malaysian. So this one answer decides the tax on every bill the patient is ever given. It is asked at registration and can be recorded or corrected here at any time.

Blank is not the same as Malaysian. A blank citizenship means nobody has asked, and Klinira says so in those words rather than assuming. Recording it applies to bills raised from now on; bills already issued keep the tax they were worked out with.

When the same person has been registered twice

It happens in every clinic: a patient comes back after five years, gives a new telephone number, and a second record is made. Both records then hold part of the truth. Joining them is on the patient search screen, under Two records for the same person, and only somebody with permission to merge sees it.

1Search, so both records are in the list in front of you.
2Click the record you are keeping — normally the one with the longer history.
3Open Two records for the same person and choose the duplicate from the list.
4Type why they are the same person. It is kept with the merge.
5Read the sentence above the button — it names which record stays — then merge.

Nothing is deleted. Every visit, note, prescription and bill moves to the record you kept, and the duplicate stays on file marked as merged — so anybody who looks it up later is sent to the right place rather than finding nothing.

The clinical history

The clinical timeline. Every visit, note, prescription and result against one patient, newest first, with the patient named at the top of it.

Filter it by kind — consultations, prescriptions, bills, documents — to find one thing in a long history. A note that was corrected shows both: the correction is current and the original is still there and still readable, because a medical record is never overwritten.

If a record fails to load, Klinira clears the screen and says so. It never leaves the last patient on screen under an error message — that is how somebody ends up reading the wrong person's allergies.