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Patient Directory & Longitudinal Clinical Dossier

This section provides an exhaustive guide to the Patient Directory and the Longitudinal Clinical Health Record Dossier in MOANA EHR. These consoles provide medical officers, nursing supervisors, and administrative clerks with a unified, 360-degree longitudinal view of every patient's clinical encounters, electronic Medication Administration Records (eMAR), physiological vital trends, laboratory diagnostics, radiology PACS studies, immunization histories, and referral tracking.

  • Authorized Roles: Hospital Administrator, Attending Doctor, Ward Nurse, Triage Nurse, Receptionist / Admission Clerk, Medical Records Officer.
  • Module Identifier: Module 02 (Patient Management & Clinical Dossier).

1. Module Overview & Clinical Data Architecture​

The Patient Management suite unifies all outpatient, emergency, and inpatient clinical records under a single Master Patient Index (MPI) identifier (MOA-XXXXX):

graph TD
    A[Patient Directory: Search, Filters & Triage Cohorts] --> B[Patient Master Demographic Header & Identity Verification]
    B --> C[1. Encounters & Visits: Chronological History]
    B --> D[2. Medications & eMAR: Active & Past Rx with E-Signatures]
    B --> E[3. Vitals & Early Warning Scores: NEWS2/MEWS Trends]
    B --> F[4. Laboratory Diagnostics: Moana-LIS Test Reports]
    B --> G[5. Medical Imaging: DICOM Studies & PACS Reports]
    B --> H[6. Immunization Registry: EIR & Printable Vaccine Cards]
    B --> I[7. External Diagnostics: Send-Out Specimen Tracking]
    B --> J[8. Referral History: Inter-Facility In/Out Telemetry]
    B --> K[9. Surgical & Theatre Records: Pre-Op & Operative Notes]
Patient Directory showing search filters, identity status, and encounter cohorts
Patient Directory showing search filters, identity status, and encounter cohorts🔍 Click to enlarge

2. Patient Directory Console​

The Patient Directory is the master census search and cohort triage interface for the entire facility.

Directory Filter Controls:​

  1. Real-Time Universal Search: Instant debounce search matching Patient Name, Moana ID / MRN (MOA-XXXXX), Phone Number, National Identity Number, or Village/City.
  2. Clinical Cohort Filter Pills:
    • All: Complete active and historical patient registry.
    • IPD (Inpatients): Currently hospitalized patients across all active wards.
    • OPD (Outpatients): Ambulatory patients with open or completed clinic visits today.
    • ED (Emergency): Acute triage and emergency room observation cases.
    • Warning (MEWS 3–4): Inpatients showing early physiological deterioration.
    • Critical (MEWS ≥ 5): High-acuity patients requiring immediate clinical escalation.
    • Discharged Today: Patients who completed discharge reconciliation today.
  3. Date Period Dropdown: Dynamic filtering across All Time, Today, This Week, This Month, This Year, or specific calendar months.
  4. Clinical Department Filter: Isolate patients by specialty department (Internal Medicine, General Surgery, Pediatrics, Emergency, Obstetrics & Gynecology, ICU).
Patient Directory Table showing care teams, vitals, and action menus
Patient Directory Table showing care teams, vitals, and action menus🔍 Click to enlarge

Patient Table Columns & Badges:​

  • Patient Identity: Verified Photo Avatar, Full Legal Name, Gender, Calculated Age / Date of Birth, and Village / Province.
  • National Identity Status Badge:
    • 🟢 Verified: Identity confirmed with National ID / Biometric token.
    • 🟡 Pending Verification: National ID token submitted; pending registry sync.
    • ⚪ Unverified: Self-reported demographic entry.
  • Unique MRN: Formal identifier (MOA-XXXXX).
  • Encounter Class Badge: OPD (Purple), IPD (Orange), ED (Red), or Discharged (Gray).
  • Bed & Ward Location: Real-time physical location (e.g., Bed 12 · Male Medical).
  • Assigned Care Team: Attending Physician and Primary Floor Nurse.
  • Latest Vitals & MEWS Score: Interactive physiological chip displaying BP, HR, Temp, SpO2, RR, and Blood Sugar with color-coded MEWS acuity.
  • Clinical Risk & Precautions Badges: Real-time visual flags for Allergies, Fall Risk, Contact/Airborne Isolation, and Chronic Illnesses.

3. Patient Master Demographic Header & Quick Actions​

Opening any patient profile reveals the Master Patient Banner:

Patient Master Header with Photo, Care Team, Allergies, and Quick Action Palette
Patient Master Header with Photo, Care Team, Allergies, and Quick Action Palette🔍 Click to enlarge

Core Header Capabilities:​

  1. Photo Capture & Upload: Capture bedside webcam photo or upload digital image with offline storage caching.
  2. Demographic Editor Modal: Edit legal name, DOB, phone with international dial codes, residential address, and preferred spoken language.
  3. Clinical Risk Tags: Add or remove known Drug Allergies (with allergen name and reaction severity) and Chronic Conditions (Hypertension, Diabetes Type 2, Asthma, Chronic Kidney Disease).
  4. Care Team Assignment Dialog: Assign or reassign the Primary Attending Physician and Primary Ward Nurse.
  5. Digital Health ID Card Generator:
    • Generates a printable, high-density National Digital Health ID Card.
    • Features encrypted QR code containing patient token, demographic barcode, photo, emergency contacts, and blood group.
Printable Digital Health ID Card with Encrypted QR Token and Barcode
Printable Digital Health ID Card with Encrypted QR Token and Barcode🔍 Click to enlarge

4. The 9 Dedicated Clinical Health Record Tabs​

The patient dossier organizes comprehensive medical records across 9 specialized tabs:

Tab 1: Encounters & Visits History​

  • Complete chronological record of every clinical consultation at the facility.
  • Outpatient OPD Visits: Chief complaint, history of presenting illness (HPI), physical examination findings, SOAP clinical consultation notes, provisional and final ICD-10 diagnostic codes.
  • Emergency Department Encounters: Triage acuity level (Level 1 Resuscitation to Level 5 Non-urgent), initial MEWS score, emergency interventions, and disposition notes.
  • Inpatient Hospitalizations: Admission date/time, admitting diagnosis, surgical procedures performed, daily clinical ward round notes, and final discharge summaries.

Tab 2: Medications & Electronic MAR​

  • Real-time electronic Medication Administration Record (eMAR) view:
    • Active Inpatient Orders: Drug generic name, brand, dosage form, strength, route (Oral, IV, IM, SC, Topical), administration frequency, start date, and prescribing doctor.
    • Cryptographic Electronic Signatures: View prescribing physician's digital signature and timestamp with one-click verification.
    • Administration Log: Tracks every bedside dose administered (Given [Green], Held [Yellow with clinical reason], Missed [Red with adverse incident log]).
    • Take-Home Discharge Medications: Reconciled outpatient prescription list sent to the dispensary.

Tab 3: Physiological Vitals & Early Warning Scores​

  • Longitudinal physiological vital signs log and trend charts:
    • Systolic & Diastolic Blood Pressure (mmHg).
    • Heart Rate (bpm) & Pulse Rhythm.
    • Respiratory Rate (breaths/min).
    • Body Temperature (°C / °F).
    • Oxygen Saturation (SpO2 %).
    • Random Blood Glucose (mg/dL / mmol/L).
  • Automated NEWS2 / MEWS Calculation: Scores each vital entry automatically and highlights physiological deterioration.
Longitudinal Vital Signs Trend Chart and MEWS Deterioration Graph
Longitudinal Vital Signs Trend Chart and MEWS Deterioration Graph🔍 Click to enlarge

Tab 4: Laboratory Diagnostics & LIS Reports​

  • Direct integration with Moana-LIS:
    • Specimen collection details (Sample type, tube barcode number, collection timestamp, phlebotomist).
    • Test battery categories (Hematology CBC, Clinical Biochemistry, Serum Electrolytes, Microbiology & Culture, Blood Bank Crossmatch, Serology, Urinalysis).
    • Analyte result grid with biological reference intervals and automatic flags for High (H), Low (L), or Critical Panic Value (!).
    • Pathologist clinical validation status and downloadable signed PDF Laboratory Reports.

Tab 5: Medical Imaging & DICOM PACS Viewer​

  • Direct integration with the hospital's DICOM PACS Server:
    • Modality requests: Digital Radiography (X-Ray), Ultrasonography (USG), Computed Tomography (CT), Magnetic Resonance Imaging (MRI).
    • Embedded Web DICOM Viewer: Open high-resolution multi-frame medical images with window leveling, pan/zoom, measurement calipers, and orthogonal reconstructions.
    • Radiologist structured diagnostic report with critical urgency flagging.
Medical Imaging Tab with Integrated DICOM Viewer and Radiologist Report
Medical Imaging Tab with Integrated DICOM Viewer and Radiologist Report🔍 Click to enlarge

Tab 6: Immunization Registry & Vaccination Card​

  • Complete Electronic Immunization Registry (EIR):
    • Standard Expanded Programme on Immunization (EPI) childhood immunization schedule (BCG, Hepatitis B, Polio OPV/IPV, Pentavalent DTP-HepB-Hib, Pneumococcal PCV, Rotavirus, Measles-Rubella MR).
    • Maternal & Adult vaccines (Tetanus-Diphtheria Td, COVID-19, Influenza, Yellow Fever, Rabies).
    • Records Vaccine Name, Batch/Lot Number, Expiration Date, Dose Sequence Number, Administering Clinician, and Anatomical Site.
    • Interactive Vaccination Certificate Generator: Click Generate Vaccination Card to produce a certified, printable PDF vaccination card with QR authentication.
Printable Certified Vaccination Card Preview and PDF Download
Printable Certified Vaccination Card Preview and PDF Download🔍 Click to enlarge
Printable Certified Vaccination Card Preview and PDF Download
Printable Certified Vaccination Card Preview and PDF Download🔍 Click to enlarge

Tab 7: External Diagnostics & Send-Outs​

  • Tracks specialized diagnostic tests referred to external accredited laboratory and imaging partners (e.g., Histopathology Biopsies, Specialized DNA PCR, Viral Load Testing, Specialized MRI).
  • Monitors courier specimen tracking numbers, order statuses (Dispatched, Received at Lab, Analyzing, Result Ready), and HL7/FHIR telemetry result ingestion.

Tab 8: Inter-Facility Referral History​

  • Comprehensive audit trail of clinical referrals:
    • Incoming Referrals: Received from community rural aid posts, urban health clinics, or district hospitals.
    • Outgoing Referrals: Specialized cases escalated to provincial or national tertiary referral centers.
    • Contains clinical transfer summaries, diagnostic attachments, and receiving clinician acceptance/delegation notes.

Tab 9: Surgical & Theatre Records​

  • Surgical suite and procedural history:
    • Pre-operative anesthesia assessment and WHO Surgical Safety Checklist.
    • Scheduled Operating Theatre bookings and assigned surgical team (Lead Surgeon, Anesthetist, Scrub Nurse, Circulating Nurse).
    • Intra-operative surgical procedural notes, implant serial numbers, and blood loss records.
    • Post-Anesthesia Care Unit (PACU) recovery logs and post-op nursing orders.

5. Patient Clinical Actions Workflow​

From any patient profile, clinical staff can trigger three major care-transition workflows:

graph TD
    A[Patient Banner Actions] --> B[1. Transfer Ward / Bed: Launches Transfer Dialog]
    A --> C[2. Care Team Allocation: Launches Staff Assignment Dialog]
    A --> D[3. Discharge & Reconcile: Launches Discharge Dialog]
    B --> E[Select Target Ward & Bed -> Mutual Locking -> SBAR Transfer]
    C --> F[Select Attending Physician & Primary Nurse -> Real-time Update]
    D --> G[Clinical Summary -> Med Reconciliation -> Bed Marked Cleaning]
  1. Patient Transfer: Opens the Inter-Ward Transfer Dialog to shift patients between wards (e.g., Emergency Holding to ICU) with mutual bed locking, medical escort checklist, and SBAR clinical notes.
  2. Care Team Assignment: Assigns primary nursing and medical coverage with immediate workstation alert routing.
  3. Discharge & Reconciliation: Executes formal clinical discharge, Authoring the ICD-10 summary, take-home e-prescriptions, and releasing the bed for housekeeping sanitization.