Electronic medical records (EMR)

In a specialty clinic a paper chart is usually held by one person at a time. While the doctor is examining, the nurse cannot add notes, the cashier cannot price the visit, and when the patient returns months later the whole file has to be hunted down again. Handwriting is hard to read, a missing allergy line can lead to the wrong prescription, and nobody can quickly answer "when was this record changed, and by whom?"

Electronic records address exactly those bottlenecks with one principle: everyone in the clinic works on the same chart, each person sees their part of the job, and every change leaves a trace. That is the foundation for the rest of Cluvix Health, from scheduling and pharmacy inventory to invoicing.

The whole module is built around a single journey, and each menu is one leg of it. You do not have to jump between several applications to complete one visit.

• Reception: booked patients are already in the queue; walk-ins just type a phone number or name to get a queue number.
• Arrival: the nurse records vital signs, reason for the visit, symptoms and history.
• Examination: the doctor examines using the specialty template and orders services and diagnostics.
• Conclusion: diagnosis coded in ICD-10, prescription, and the treatment plan.
• Signing: the doctor signs, the record locks, and who signed and when is recorded.
• Payment: the visit, services and diagnostics are paid for right inside the chart.

The Reception and Examination screen is today's queue and the place where all three roles start. The front desk receives new arrivals, the nurse records vital signs, and the doctor opens the chart to examine. The list defaults to today, so whoever is waiting shows up immediately, and clicking a patient's name opens that visit's exam screen directly.

When the patient is present, the nurse logs arrival time, the consulting doctor, and measurements such as height, weight, blood pressure, pulse, temperature, respiratory rate and SpO₂, together with the reason for the visit, symptoms and history. Numbers entered once here flow straight into the chart; the doctor does not have to ask again and retype. Each status change, from Not arrived to Arrived, In consultation, In treatment and Left, is timestamped, so at the end of the day you know how long patients waited and how long they stayed.

The doctor's exam screen is divided into tabs that follow the real order of work: Exam, Orders, Conclusion, Payment, Links, Progress and Documents. Exam and diagnosis text can be filled from templates the clinic has prepared, so the doctor edits only what is different in each case instead of writing from scratch. Dentistry has its own tooth chart, and other specialties use their own templates.

Diagnoses are picked from the ICD-10 catalog. The chart list shows both code and disease name, and this same data feeds the Top diagnoses report. A prescription written in the Conclusion tab appears in the Issued prescriptions screen, where the pharmacy dispenses: the software records the quantity dispensed per drug and deducts stock accordingly. The prescribed and dispensed quantity columns sit side by side, so an under-filled prescription is easy to spot.

Prescriptions written at a medical facility are sent to the National E-Prescription System as required by the Ministry of Health. In Cluvix Health this sits right on the prescription screen: four counters, Not sent, Sent, Error and Sending, show the connection status, and clicking one filters by that status. A prescription that needs to go out again can be resent, and the software records how many times it was sent. Prescriptions that fail because of the network or a busy national portal are retried automatically up to a configured number of times, so staff do not have to remember each one.

The connection is configured once per medical facility, and each doctor is linked separately right in the software. When sending in batches, the prescriptions must belong to the same branch because each branch connects with its own facility details.

When a doctor signs a chart, it moves to Completed and is locked. The doctor ticks a confirmation that they reviewed the content and take responsibility for it, and can add a signing note, such as "signed after consultation". If the clinic uses a CA digital signature, the software also asks for the provider and the doctor's personal signing account; that information is used only for that signing and is not stored. The software keeps a content fingerprint of the chart at the time of signing to show it was not altered afterwards. Only doctors registered by the facility can sign.

A signed chart cannot be deleted. To change content it must be reopened with a stated reason, and every reopening is recorded in the log. The chart log shows who created, edited, signed and reopened, and when. Under Circular 46/2018 this is the audit trail of an electronic chart, and also a quick place to answer questions about an old record. The dashboard also singles out charts that need signing now: overdue by more than 24 hours, sessions not closed for over 24 hours, and late signing batches.

Every patient has a single record with its own patient ID, following them through every visit: come back next year and it is still the same record. It holds administrative data (name, date of birth, identity documents, address), health insurance (card number and coverage level), medical data (blood type, medical history, allergy history, important notes) and a guardian or contact person, which matters for pediatric and elderly patients. The patient category, whether self-pay, insurance, free or other, determines how the visit is priced.

The allergy and important-notes fields reappear to the doctor during the exam and while prescribing, so asking once when the record is created serves every later visit. A patient is the clinic's customer seen from the clinical side, so a record created in customer management or by walk-in reception is shared, with no double entry. Customer care and doctors see the same person, each from their own angle.

When a patient needs to go to another department mid-visit, the doctor creates a referral inside the visit, in the Links tab. There are three types: within the facility, to another facility, and escalation to a higher level, with the receiving facility and department, the reason, and a chart summary attached. The referral passes through Pending, Transferred, Received and Completed, so the receiving side opens it with full context and does not have to ask again.

At the cashier, the Payments screen answers one question: how much is still owed for this visit. Each row carries four figures: total fee, insurance share, patient share and amount paid; filtering by Unpaid at the end of each shift gives the list to follow up. The chart list can also export the BC15 form (health insurance fund expenditure report) and the S03 form (outpatient statistics register) directly from existing data, so nothing is compiled by hand.

With paper charts, everything lives in one copy that can only be found by hand. With a standalone EMR, data still has to be copied to billing, pharmacy inventory and customer care. In Cluvix Health the chart is part of the same platform: prescriptions deduct pharmacy stock, visit costs flow into payments, and the patient record is shared with customer management. That is a significant reason to choose a unified platform over stitching three tools together.

The module is for doctors, nurses, reception staff and cashiers. Users only see the modules their account is permitted to use, and since a chart is a medical record, access usually opens for exactly these groups.