SNOMED is a descriptive documentation language that differentiates between model levels and observation classes. The data model in the ifa program is completely compatible with the SNOMED concept. As soon as the reworked ophthalmic SNOMED nomenclature is finished it will be possible to link custom finding abbreviations (observation codes) with SNOMED codes with the so-called mapping program. In the data model it is also possible to link certain findings with proposed diagnoses. For example, the finding ”visual field loss“ could be linked with several glaucoma diagnoses. If these links have been set, when entering this finding, the linked diagnosis will be recommended to select from. The user can simply click on the appropriate diagnosis or enter a different or new diagnosis into the medical record. These links on different levels help to simplify data input and more than that help to establish the use of certain documentation guidelines. The abbreviations and the corresponding descriptions of observation classes are displayed in the computerized patient history, printed out in reports or displayed in interfaces. 2.6 Special-Documentation Ophthalmic documentation can cover all areas of ophthalmology because of the flexibility in the program’s design (see 30 observation classes). Additionally, the CPR software offers special data models for 2 extra areas in ophthalmology: Ophthalmic surgery Orthoptics Both of these documentation areas are integrated in a way that they are directly linked with one another. In practice, this means that all general findings and diagnoses are also available for the OP documentation and patient orthoptics records. 2.6.1 Ophthalmic Surgery Additional data records are supplied for documenting surgical cases. Types of OP’s (e.g. phaco) can be preset to include all of the standard steps for that OP. Complete documents i.e. OP reports are linked with these OP types. Changes can be added with customized information to accommodate any deviations in the procedures for that surgery (e.g. complications). A data record generator (designer) exists in the OP program. This designer can be used to generate customized special data records that are not already included in the program. Data records for lens specifications already exist in the OP program.
ifa systems AG Augustinusstr. 11 b 50226 Frechen, Germany phone: +800-43222557 www.ifasystems.de
ifa united i-tech Inc. 1850 SE 17th St. Ste. 107 Ft. Lauderdale, FL 33316, USA phone: +1-888-4432367 www.ifa4emr.com
ifa systems iberia S.L. Cami de Can Manuel 24 07120 Son Espanyol - Espana phone: +34-971-438555 www.ifasystems.es