Anamnesis and Findings Praxis Desk

In the patient record you capture anamnesis and findings as free-text documentation entries. Each entry is stored as a versioned document in the record and in the history.

Where to find anamnesis entries in the patient record

1. Open the record you want in the patient list.
2. The record shows an entry panel at the top with the tabs Anamnese, Therapie, Befund, Procedere, Diagnose, Rezept, Datei, and Notiz.
3. Click the Anamnese tab.

If only one type is configured, the entry form opens directly. If there are several types, you choose the right tab first.

Fig. 1The entry panel with the Anamnese tab active.

Prerequisites

• Your license includes the module for anamnesis and findings.
• You have permission to create, edit, or delete anamnesis entries.

Required license

Anamnesis and findings documents are only available if the module is enabled in your license. If the module is not active or the permission is missing, the anamnesis area does not appear in the patient record.

Adding an anamnesis entry

1. Click the Anamnese tab in the record's entry panel (or an individual anamnesis type, if configured).
2. Enter the text in the editor. This field is required.
3. Optionally pick a template and insert it into the editor.
4. Optionally select the treating provider.
5. Check the date field and adjust it if needed.
6. Click Save.

After saving, offisy shows the message "(Type name) was created.", for example "Anamnesis was created." The entry then appears in the record's History tab.

Fig. 2Saved entries appear in the History tab, with a type abbreviation (here 'Anamnese' and 'Ntz') and a date.

Editing an anamnesis entry

1. Open the action menu of the entry you want in the History tab.
2. Select Edit.
3. Adjust the text, the treating provider, or the date.
4. Click Save.

offisy creates a new version of the entry when you edit it. The change stays traceable in the History tab.

Deleting an anamnesis entry

1. Open the action menu of the entry you want in the History tab.
2. Select Delete.
3. Confirm the prompt.

Configuring anamnesis types

You can create your own anamnesis and findings types, for example "Anamnesis," "Initial finding," or "Follow-up."

1. Open the document settings.
2. Switch to the tab for individual anamnesis types.
3. Click Add in the individual types section.
4. In the add document type dialog, enter the name and the abbreviation.
5. Choose the color in the patient record, the color for printed status, and the color for unprinted status.
6. Turn on Show in waiting room if needed.
7. Click Save.

To edit an existing type, select Edit from its action menu. The default type shows a Default badge in the list.

Permissions

• Creating an anamnesis entry: permission to create anamnesis entries.
• Editing an anamnesis entry: permission to edit anamnesis entries.
• Deleting an anamnesis entry: permission to delete anamnesis entries.
• Configuring anamnesis types: access to the document settings.