The user can record and view patient information, using standard structured and free-text formats to describe and detail patient problems, diagnoses, procedures, complications, and all aspects of medical noting.

MAXIMS Clinical Documentation ensures the multidisciplinary care of a patient; supports the recording of clinical details through the completion of standard and locally defined proformae; facilitates nursing assessments, interventions and plans of care and supports the generation of clinical audit reports.

MAXIMS Clinical Documentation uses the concept of “Episodes of Care”, “Problem Groups” and “Care Contexts”, as containers within which all other information relating to a particular ‘problem’ or ‘Episode of Care’ may be attached.

Within the system, maximum use is made of graphics and diagrams

Key Functionality

• Patient Summary - Provides a summary view of the episode, including problems, diagnosis, procedures, complications, and clinical contacts.
• Medical Assessment - Provides the capture and review of present complaint, past medical history, social history, family history, and medication at admission, allergies, and system review (generic) in the context of this episode.
• Clinical Notes List / Clinical Notes – allows a variety of clinical notes to be recorded within the patient record and sorted in reverse chronological order (most recent entry at the top). Presented in diary format, the view may be further filtered to display only those notes within a single discipline (e.g. Nursing, Oncology, etc.)
• Problems/Diagnosis/ Procedures/Complications – Coding - Ability to record details of problems, diagnosis, procedures and complications and to code these, using locally defined terms with mappings to SNOMED, CT and/or READ3 codes.
• Problems/Diagnosis/ Procedures/Complications-Linking - Ability to record details of relationships between problems, diagnosis, procedures and complications (e.g. Complication “Wound Infection” is associated with Procedure “Debridement of Leg Ulcer”).
• Nursing Assessment - Ability to record details of multiple nursing assessments for a patient.
• Nursing Plan of Care - Ability to record a plan of care for the patient.
• Discharge Management - Summary of Noting, Discharge Medication and Discharge Document generation - Provides for the capture and review of discharge planning information including details of medication to be taken after discharge.
• Observations (Vital Signs, Urinalysis, Fluid Management) - A set of general observation screens to record, monitor and review vital signs including temperature, pulse, respirations and blood pressure (TPR & BP), oxygen saturation, peak-flow measurement, urinalysis, capillary blood glucose, pain level, the Glasgow Coma Scale and fluid input/output. Results of TPR & BP and fluid management can be viewed in familiar graphical or tabular formats.
• Patient Assessments - Provides the ability to define further assessments and datasets to be recorded against the patient record.
• Outpatient Noting – Supports the patient review in Outpatients with clinical notes review and capture; clinical data items review; and the capture and generation of outpatient letter(s).
• Clinical Audit is available through the use of summary screens and the reporting functionality.

Benefits

• Provides total flexibility as the hospital can construct new screens as required.
• Improves efficiency and reduces risk, as users have easy and immediate access to all patient information, including historical data.
• Supports management control as assessment/monitoring of procedures/activities undertaken within the hospital, is provided through the reporting tools.
• Immediate, intuitive and efficient access to up-to-date patient information, using a standard web browser (IE6) to view and maintain data.
• Improved user performance as screens can be set up to match working practices for each class of user.
• Assists with care delivery process as workflow is supported for each class of user.
• Simplifies use as information is presented in a concise and meaningful Navigation Bar.
• Immediate access to supporting data through the use of the “drilling down” technique.
• Quick, intuitive and structured data entry ensured by the use of dialogue boxes containing drop down lists.
• Reduces training overload through the use of a Web based system.
• Rapid and easy deployment via local and wide area networking through the use of internet browsing technology.
• Reduced hardware and implementation requirements through the use of web functionality.