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Digital Clinical Documentation Software
"It's time for more efficient and accurate clinical notes"
from Oncology Information Capture System (OnICS Ltd)
4.0) iNOTZ Medical Content
4.1) Demographics (NOT menu-driven)
4.1.1) Name, address, Telephone, Contact person, etc.
4.1.2) Unique ID, NHS number, (MRN USA)
4.2) History of Present Encounter
4.2.1) Symptoms of illness/complaint
4.2.2) Questionnaires (patient participation with or without help)
4.3) Examination findings
4.4) Past Histories (Medical, Surgical, Cancer)
4.4.1) Patient
4.4.2) Relatives (Family histories)
4.5) Review of systems (USA market, some overlap with 4.4.1)
4.6) Performance status
4.7) Investigation requests
4.7.1) Radiology
4.7.2) Biochemistry
4.7.3) Haematology
4.7.4) Nuclear medicine
4.8) Investigation results (imported from external source)
4.9) Biopsy (needle, core, excision)
4.10) Biopsy result (imported from external source)
4.10.1) Morphology
4.10.2) Molecular pathology markers (if available)
4.11) Chemotherapy determinants (if applicable)
4.11.1) Height, weight
4.11.2) Surface area
4.12) Treatment Decision (MDT, for UK see appendix 7.1)
4.12.1) Single modality (surgery, radio-, chemo-, molecular -therapy)
4.12.2) Combined modalities Strategic Therapy Vector (STV) e.g.-
4.12.2.1) SGY -> RTY
4.12.2.2) RTY -> SGY
4.12.2.3) SGY -> CTY -> RTY
4.12.2.4) CTY -> SGY -> RTY
4.12.2.5) CMT (concomitant chemoradiation, RTY+CTY)
4.12.3) Molecular therapy
4.12.3.1) NK cell activation (Immunotherapy)
4.12.3.2) Vaccination
4.12.3.3) Gene editing using CRISPR/Cas9
4.13) Radiotherapy Planning & Simulation Notes (for USA, see appendix 7.2)
4.13.1) HDR cylinder placement
4.13.2) HDR needle placement
4.13.3) HDR SAVI applicator
4.13.4) CT Simulation note
4.13.5) Prior to radiation treatment
4.13.6) HDR Valencia skin applicator
4.13.7) Block verification of electron field
4.14) Treatment PRESCRIPTIONS
4.14.1) Cancer modality SPECIFIC radiotherapy
4.14.2) Cancer modality SPECIFIC chemotherapy
4.14.3) Non-specific (e.g. diabetes, heart failure etc.)
4.14.4) Cancer specific molecular therapy
4.15) Treatment Delivery: PROGRESS and REVIEW
4.15.1) Radiotherapy (for USA, see appendix 7.2 )
4.15.1.1) HDR Valencia treatment
4.15.1.2) HDR Prostate Brachytherapy
4.15.1.3) Prostate Brachytherapy – Monotherapy first fraction
4.15.1.4) Prostate Brachytherapy – Monotherapy second fraction
4.15.1.5) Tandem and Ring
4.15.1.6) Vaginal cylinder
4.15.1.7) Intravaginal ring
4.15.1.8) AccuBoost as definitive therapy
4.15.1.9) AccuBoost Treatment
4.15.1.10) SAVI Procedure and removal
4.15.1.11) SAVI Procedure
4.15.1.12) Volumetric study
4.15.2) Chemotherapy
4.15.3) Surgery
4.15.4) Molecular therapy
4.16) Treatment modifications due to
4.16.1) General debility
4.16.2) Side-effects
4.17) Treatment AUDIT
4.18) Summary
4.19) Follow-up annotations (± investigations & results)
4.20) Letters and Consent Forms (for USA, see appendix 7.2)
4.20.1) Headed letter (family practitioner, referring physician, etc.)
4.20.2) Blank note (simple letter which doesn’t fit a set note type)
4.20.3) Special Treatment Procedure for 77470 billing requirements
4.20.4) Radiation clinical treatment planning consent
4.20.5) Special physics consult request for 77370 billing requirements
4.21) Off-line data acquisition (when not network connected)
4.22) Data analysis
4.22.1) Total patient numbers
4.22.2) Numbers by category
4.22.3) Outcomes