E-examination
This page describes how to take an examination from the draft to closing in NHIS, and what to do when you need to fix it. The preparation of the location and the specialist is in NHIS (HIS BG).
New examination
Open "E-Examination" from the client row in the appointment.
A new examination takes the specialist and the location from the appointment in the schedule. By default, the specialist's role is titular, and the primary diagnosis comes with its diagnosis role, "Clinical status" and "Verification status" filled in — change only what is different. The patient data is filled in from the patient's last examination. For a first examination, the name, gender and date of birth come from the client record.
When you pick a specialist and a location, the system takes the UIN, the specialty and the registration number from their own settings. If the role is a substitute or contracted doctor, a "Substitute specialist" field appears as well.
Stages of the examination
At the top of the examination is a bar with its NHIS status: the NRN with a copy button and the stage label. Until the examination is submitted, it reads "The examination has not been opened in HIS yet."
| Stage | What it means | Buttons at the bottom |
|---|---|---|
| "Draft" | Saved in the application, without an NRN. | "Save", "Save and open in HIS", delete, download and print the sheet |
| "Open" | Submitted to NHIS, has an NRN. | "Save", "Close in HIS", download and print the sheet |
| "Closed" | Closed in NHIS. | "Correct", download and print the sheet |
| "Correction" | A correction that is started but not sent yet. The label sits next to "Closed". | "Save", "Send correction to HIS" |
| "Canceled" | Voided in NHIS. | "Download outpatient sheet", "New examination" |
In every stage except "Canceled", the bar at the top has a "Check in HIS" button. It compares the examination with NHIS and updates its stage in the application. Use it when you are not sure whether the last action reached NHIS. For an open or closed examination, or one in correction, "Void" is next to it.
You can delete only a draft. An examination with an NRN is already in NHIS, which does not allow deletion — void it instead.
How the screen is arranged
The examination opens as "E-Examination" and follows the order of the actual work:
- "Patient information"
- "Examination and specialist"
- "Medical history"
- "Objective condition" — with "Pregnant" and "Nursing mother" where they apply
- "Assessments"
- "Primary diagnosis"
- "Accompanying diseases"
- "Performed specialized activities"
- "Therapy"
- "Referrals" and "Prescriptions" — once the examination is saved (see E-referrals and e-prescriptions)
"Accompanying diseases" and "Performed specialized activities" are added row by row with "Add": an ICD code with additional information, or an activity code with a count.
Once the examination is open, the patient data block collapses. Under the name there is an "Address:" line with the full address or "Not specified". You open the details with "Show details".
In a closed or voided examination, a section without data is not shown.
Next to the text fields there is a "Last used values" button. It offers values from recent examinations of the specialist selected in "Examination and specialist". While no specialist is selected, there are no suggestions. To fill in a whole examination at once, use a template or a previous examination — see Examination templates.
The opening data are locked
Once the examination is open in NHIS, the data it was opened with cannot be changed: the examination start, the type, the financing, the health region, the specialist, the role, the location and the patient. To change the type or the financing, send a correction after closing. For anything else, void the examination and create a new one.
The patient's address stays editable — you can complete it in an open and in a closed examination.
Steps: from a new examination to closing
- Open "E-Examination" from the client row in the appointment.
- Fill in the data — by hand, from a template, or with "Copy from previous examination".
- Press "Save" to save the examination in the application without submitting it to NHIS.
- Press "Save and open in HIS" to submit it. After a successful submission you see the NRN and the "Open" label.
- When the examination is ready, press "Close in HIS".
To save, fill in the required fields in "Patient information", "Examination and specialist" and "Primary diagnosis". "Medical history" and "Objective condition" are needed only for closing.
You can also work on paper — see Outpatient sheet and patient signature.
What is required for closing
Before "Close in HIS" you need:
- "Medical history" and "Objective condition";
- a "Primary diagnosis" with its role, "Clinical status" and "Verification status".
"Onset of symptoms" is not required — a preventive examination, for example, has no complaints.
Depending on the examination, these may be required as well:
- "Based on document" — the NRN of the referral or of the primary examination, when the examination is a follow-up or an NHIF examination with a specialist;
- "Preventive examination type" — for a preventive examination;
- "Contagious disease: quick notice category" — when the diagnosis is contagious;
- "Substitute specialist" with a filled-in UIN — when the role is a substitute or contracted doctor;
- for a screening — a "Primary diagnosis" of Z00.0, with the findings entered as "Accompanying diseases".
If something is missing, closing stops before the signing step — not after it. The messages you may see:
- that the medical history or the objective condition is missing;
- "No diagnosis entered";
- "Clinical status or verification status of the diagnosis is missing".
Correcting a closed examination
A closed examination is not edited directly. To change it:
- Press "Correct". "Correction" appears next to the "Closed" label.
- Change the data. The dates, the specialist, the substitute specialist, the role, the location and the patient cannot be changed.
- Fill in "Reason for correction".
- Press "Send correction to HIS". On success you see "The correction was sent to HIS."
Until the correction is sent, you can save it with "Save" and continue later.
The patient's address in a closed examination needs no correction: complete it and press "Save".
Voiding
- Press "Void" in the bar at the top.
- Fill in "Reason for cancellation".
- Press "Cancel examination in HIS".
If the examination has issued referrals or prescriptions, void them first. Otherwise you see "First cancel the referrals and prescriptions of the examination" with their NRNs.
The reason for voiding stays visible in the bar of the voided examination.
A voided examination has a "New examination" button that starts a new draft for the same appointment. This is how you fix an examination with the wrong patient, doctor or date.