SOAP Electronic Health Record

1- Allows recording of screening or preparation for each patient (weight, height, blood pressure, pulse rate, respiratory rate, waist, hip, head circumference, capillary blood glucose, saturation) during pre-consultation;

2- Records procedures performed during screening;

3- Informs the discharge with referrals for users who do not require medical care;

4- Automatically calculates BMI (Body Mass Index), WHR (Waist-to-Hip Ratio), and nutritional status according to the patient’s age (life cycle);

5- Allows configuring the mandatory filling of weight, height, and blood pressure according to the patient’s life cycle (child, adolescent, adult, and elderly) at each service location;

6- Allows pain assessment, risk classification (Manchester Protocol), and Glasgow Coma Scale for prioritizing care at Emergency Care Units;

7- Allows informing consistent material and ICD for each exam;

8- Records prescription medications, medical certificates, attendance statements, instructions, test requisitions, and referral guides;

9- Records nursing care with patient guidance using the CIPESC methodology – International Classification of Nursing Practices in Public Health;

10- Records clinical information (allergies, diseases) of patients at the time of medical care;

11- Allows viewing the patient’s appointment history by type (medical consultations, dental visits, tests, and transportation);

12- Allows using a photo in patient registration;

13- Provides full access to the patient’s previous appointments in chronological order to the doctor;

14- Allows viewing scanned documents for each patient treated;

15- Allows recording of medical history and physical examination during each appointment, parameterized according to the types of information defined by the health department;

16- Allows requesting medications according to products standardized by the pharmacy, integrating prescriptions with inventory;

17- Contains results and reports of tests requested in the patient’s electronic record;

18- Controls medication requests according to unit stock and allows prescription of medications outside the standardization of the Health Department;

19- Automatically imports test results into the electronic record;

20- Allows issuance and registration of certificates, referrals, and instructions;

21- In outpatient care, automatically shows the doctor the availability of medication stock at the time of request;

22- Allows consultation of the complete dental appointment history for each patient, including the full dental chart, involved professionals, and procedures performed;

23- Access to medical record information is restricted to doctors (only of patients under treatment), experts, and medical regulators (only patients in the regulation process);

24- Allows healthcare professionals to fill out forms compatible with those of e-SUS.