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 customer list.
2. Switch to the documents area of the record.
3. Choose the type you want, for example Anamnesis.

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

Prerequisites

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

Benötigte Lizenz

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. Choose the anamnesis or findings type you want in the documents area.
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 and in the history.

Editing an anamnesis entry

1. Open the entry you want in the record.
2. Adjust the text, the treating provider, or the date.
3. Click Save.

offisy creates a new version of the entry when you edit it. The history stays traceable.

Deleting an anamnesis entry

1. Open the action menu of the entry you want to delete.
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.