Medical records

The Medical records module is the medical department’s workspace. Each visit (a consultation, an intervention, a hospital stay…) belongs to a citizen, the patient. It carries an assessment (severity, injuries placed on a body chart), the fields of its type (vital signs included), the billed procedures taken from your procedures list, and the caregiver’s signature. A surgery is attached to it with an operative report. At the top of the record, the patient’s medical history stays at hand: blood type, allergies, medication…

Marcus Bell’s medical record

Find a patient

At the top of the screen, the Patient field (Choose a patient) opens a search: type at least two letters of a first name, last name, date of birth or phone number, then pick the citizen from the list (10 results at most; arrows and Enter on the keyboard). Their medical record opens below. The cross button next to the field closes the patient’s file.

The search only needs Medical records › See medical records: no access to citizen records is required. It only offers citizens who already exist: an unknown patient is first created in the Citizens module (you need Citizens › Create a citizen).

The patient record

The medical record shows only the essentials about identity: photo, name, date of birth and, if relevant, the Deceased badge. The Open citizen profile link leads to the full citizen record; it only shows with Citizens › See citizens.

Four figures sum up the record:

Figure	What it shows
Visits	the number of recorded visits
Outstanding	the total of Unpaid visits, in your organization’s currency
To sign	the number of visits not signed yet
Last visit	the date of the most recent visit, or Never

These figures cover the 500 most recent visits; beyond that, a note says so below them.

Medical history

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The medical history at the top of the record

The Medical history card, marked Medical confidentiality, opens the record. It sums up what a caregiver must know before acting:

• the Blood type (A+, A-, B+, B-, AB+, AB-, O+, O-), or Unknown;
• the fields of your Medical history sheet. The starter pack offers Allergies, Current medication, Medical history, Emergency contact and Contact phone.

Edit opens the medical history panel (you need Medical records › Edit medical history). The card says who updated it and when (“Updated by …, …”). History unfolds each change, newest first, with each value before → after.

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The medical history log: each change, before and after

The history fields are set in Settings › Forms, Medical history sheet: add, rename or remove the ones your server uses. The blood type is a base field: it can be renamed or hidden, but not deleted.

The medical history is only visible with Medical records › See medical records: a police officer opening the same patient’s citizen record sees none of it.

Blood type read in game

With the game integration, on QBCore and Qbox, the bridge reads the character’s blood type (metadata.bloodtype) and sends it to the MDT. As long as nobody has entered a blood type, it is the one shown, with the note “Read in game, read-only.”. If the type entered in the MDT differs, the card says so (“The game says O-”): check which one is right. Each reading that changes the value enters the history on behalf of the system (“The system read the blood type in game”). SuperMDT never changes the blood type in game. ESX has no standard blood type: nothing is read.

Visits

Under Visits, visits are listed newest first, 10 at a time. The counter shows how many are displayed, and Show more loads the next 10.

Each visit shows:

• its number (no. 12; numbering is specific to your organization), title, date and time, and author;
• its type (“Consultation”, “Emergency response”, “Hospital stay”… in the starter pack) and, if set, its Severity;
• its payment status: Paid, Unpaid, or Free when nothing is billed;
• its signature: Signed by … with the date, or To sign;
• its Injuries: a compact numbered list (body element, type, colored severity, note), then the injuries off the chart; Show the body chart unfolds the chart (see Reading the chart);
• its operative reports, if any: Operative report (1) or Operative reports (2) unfolds them (see Operative report);
• the Issued documents drawn from this visit (see Export, issue a document);
• the billed procedures with their price (and their range, for a procedure with a range), and the Total;
• the status of the In-game bill, if your department bills care in game.

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A signed visit: severity, injuries, procedures

When the visit’s type has filled-in fields (vital signs included), Details unfolds them and Hide details folds them back. History unfolds the visit’s history (see A visit’s history). An edited visit shows “Edited by …, …”.

Record a visit

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The visit panel: assessment, injuries and procedures

1. Open the patient’s record and click New visit (the button only shows with Medical records › Record a visit).
2. Pick the Visit type. Types are the forms you create in Settings › Forms, under Medical record types; a type restricted to a department is only offered to its members. No type records a visit without custom fields.
3. Give it a Title (required, 120 characters at most), for example “Gunshot wound, check-up”.
4. Check the Date and time: it defaults to now, in your organization’s time zone.
5. If you have the permission in several departments, pick On behalf of which one you record.
6. Under Assessment, set the visit’s Severity and the Injuries: on the body chart, or as a list by zone (see The assessment and Body chart).
7. Fill in the type’s fields under Information: in the starter pack, the vital signs have their own section there.
8. Under Billed procedures, add procedures one by one with Add a procedure (30 at most). The same procedure can be added several times; a line’s cross button removes it. For a procedure with a range, enter the chosen price (“Between … and …”). The Total updates as you go.
9. If you have Medical records › Sign a visit, the Sign now switch signs the visit as soon as it is saved.
10. Click Save visit.

The assessment

Vital signs

Blood pressure, pulse, oxygen saturation, temperature, blood sugar, consciousness (AVPU scale: alert, responds to voice, responds to pain, unresponsive) and Glasgow score: in the starter pack, these are fields of the visit type, grouped in its Vital signs section. Add, remove, rename or bound them like any field, type by type, in Settings › Forms.

Severity

The visit’s overall Severity comes from your Medical severities list (starter pack: Minor, Moderate, Serious, Critical), or Not assessed. Its tint comes from the category set in the list, never from the label.

Injuries

Injuries are entered in two ways, with the Body chart | List switch: on the body chart, by clicking the injured element (a region, a bone, an organ), or by zone. For an injury by zone, Add an injury adds a line (30 at most):

Field	Where it comes from
Zone	your Body zones list (head, neck, chest, arm, leg…)
Side	left, right or both sides: only offered for a zone that has a side
Injury type	your Injury types list (gunshot wound, fracture, burn…)
Injury severity	your Medical severities list
Note	a short text (“exit wound, active bleeding”)

These lists are managed in Settings › Reference lists. A zone’s code identifies it: it is what places an injury entered by zone on the chart (see From the list to the chart). The starter pack sorts the zones in anatomical order, head first, with the Order column of the Body zones list: change the numbers to reorder; without an order, zones are sorted by code.

Note

Without the Body zones, Injury types and Medical severities lists, the panel tells you so: install them from the Medical department step of getting started, or create them in Reference lists.

Sections enabled type by type

Severity, Injuries and Billed procedures are base fields of the visit type: in Settings › Forms, each type can rename or hide them. In the starter pack, the Consultation hides injuries, which the Emergency response shows. A hidden section doesn’t show in the panel, and the server refuses to save anything into it.

Body chart

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The visit panel in Body chart mode: the body, the layers and the annotations

In the visit panel (New visit or Edit), the Injuries part of the Assessment starts with a Body chart | List switch. It defaults to Body chart; on a narrow screen (a phone, under 640 px wide), to List. The panel widens when the Injuries part is visible, to make room for the chart. Both modes show the same injuries: switch at any time.

Annotating the chart

The chart shows the body in Front or Back view, with three layers: Surface (body regions), Skeleton (bones) and Organs.

1. Pick the view and the layer, then click the injured element: a region, a bone or an organ. The annotation panel opens.
2. Check the Element (you can change it from the panel).
3. Pick the Injury type (Injury types list) and the Severity (Medical severities list).
4. Optionally add a Note (300 characters at most) and, with Place a point, a precise marker on the element (the entry wound, for example); Remove the point clears it.
5. Click Add annotation.

An annotation’s color comes from the Tint of its severity in the list: green for minor, amber for moderate, orange for serious, red for critical. Next to the chart, the Annotations list shows each injury with its number, the same as on the body marker, and the “… of 50” counter: a visit holds 50 annotations at most. Click an annotation in the list to reopen it: Save keeps your changes, and holding Delete down removes it.

To aim precisely:

• Zoom: mouse wheel, pinch on a touch screen or the Zoom in and Zoom out buttons; Whole body goes back to the full body; Zoom to goes straight to the head and neck, the torso, a hand, a knee or a foot. A small bone of the hand or foot is picked up close: click it from afar and the chart first zooms in on the region.
• Moving around: once zoomed in, hold the click (or your finger) and drag to move the body. A drag never opens the annotation panel: only a click without moving annotates.
• Keyboard: Tab to enter the chart, arrows to move between elements, Enter to annotate the chosen element, Esc to close the annotation panel.

Injuries off the chart

Below the chart, Injuries off the chart keeps the injuries entered by zone (Body zones list) that the chart can’t place: a paired zone without a side (chest, abdomen, pelvis), the back, or an injury without a type or severity. Add an injury adds one (30 at most), with the same fields as injuries by zone.

List mode

In List mode, the chart’s injuries show as lines: location, view and layer, type, severity, note and a button to remove it. The injuries by zone follow, editable as usual.

From the list to the chart

An injury entered by zone moves onto the chart, when you switch to Body chart mode or when you save, if:

• its zone matches a region of the chart, from the zone’s code (head, neck, arm, hand, leg, foot…; a code can also be written region.thigh);
• it has a Side when the zone has one;
• it has an Injury type and a Severity.

An injury on Both sides becomes two injuries, one left and one right. A paired zone without a side (chest, abdomen, pelvis) or the back stays in the list, under Injuries off the chart.

For administrators: existing visits

A migration placed on the chart the injuries of visits already recorded that met these conditions. It is only a change of shape: the visits’ signature and history are untouched.

Reading the chart

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The chart unfolded on a visit: numbered markers, severity colors, linked list

On a visit’s card, Injuries shows a compact numbered list (element, type, colored severity, note), then the injuries off the chart. Show the body chart unfolds the chart, read-only: injured elements are colored by severity and carry their number. Every injury of the displayed view and layer shows at once; several injuries on the same element each get their own marker, side by side. The chart opens on the view and layer that hold the most; the numbers next to Front, Back and each layer tell how many injuries are there. The list is linked to the chart: hovering a line highlights the element, clicking a line switches to the right view and layer. Hide the body chart folds it back.

On the in-game tablet, the assessment and the chart use the same screens.

Chart sources

The chart is drawn in-house from public domain and CC0 sources: skeleton after Mariana Ruiz Villarreal (LadyofHats), public domain; organ placement after Mikael Häggström, CC0.

Procedures and prices

Procedures come from your Medical procedures list (Reference lists). If you have several, the List menu picks which one to browse.

A procedure has a fixed Price, or a range when its Maximum price column is set. The starter pack offers several: consultation from 100 to 250, emergency consultation from 250 to 500, psychological assessment from 200 to 1,000, medical certificate from 50 to 150. The caregiver enters the price between the two bounds; the server brings any amount outside the range back to the nearest bound.

Each procedure’s price is locked in when the visit is saved: changing a price in the list later doesn’t change visits already recorded.

Tip

No procedures list yet? The screen tells you: create it in Settings › Reference lists, with the starter pack if you want a base, or install the whole medical pack from the Medical department step of getting started.

Sign a visit

The signature attests a visit’s content: Signed by …, with the date and time. Sign when creating it (Sign now) or later with Sign on the visit (you need Medical records › Sign a visit). You can sign a colleague’s visit, for example when a physician validates a paramedic’s visit.

If your department bills care in game, the signature is what sends the bill: see The in-game bill.

Edit a visit

Edit on a visit reopens its panel (Edit visit) with everything entered: type, title, date, assessment, fields, procedures. Save changes keeps the changes.

• Your own visit: Medical records › Edit own visits.
• A colleague’s visit: Medical records › Edit all visits.

Editing a signed visit removes the signature

A signature can’t cover content it hasn’t seen. A signed visit that is edited loses its signature and goes back to To sign: the panel warns you before you save. Nothing is lost: the history keeps the old signature and every change.

If the care bill hasn’t been sent in game yet, it follows: its amount changes, or it is cancelled when the signature drops. A bill already sent is never issued a second time.

A visit’s history

History, on a visit, unfolds everything that happened to it, newest first: who, when and what. Each edit lists its changes before → after (title, severity, injuries, fields, procedures…), for example “Severity: Serious → Critical”.

Chart injuries follow the same rule, one line per injury, for example “Injuries: Right radius (Front) · Fracture · Serious · note → ∅” for a removed injury. A marker that was only moved gives “… · marker moved”.

Entry	What it says
recorded the visit	the creation
edited the visit	each changed section, before and after; on a signed visit, the line “Signature: … → ∅”
signed the visit	the signature
changed the payment	a visit marked paid or unpaid by hand
The system received the care bill payment from the game	the in-game payment

The history is covered by medical confidentiality: it is only visible with Medical records › See medical records. It shows a bounded number of entries, with Show more.

Paid or unpaid

A new billed visit is Unpaid. When the patient pays, click Mark as paid on the visit; Mark as unpaid reverses it (you need Medical records › Mark a bill paid). The Outstanding figure updates immediately. A Free visit has no such button.

The in-game bill

When your medical department bills care in game (Care billing setting in Settings › Game › Integrations, see Fine collection › Medical care), the bill is sent in game when the visit is signed, for a patient who is a game character. A visit only ever sends one bill.

The visit then shows the In-game bill: being sent, waiting for the character to connect, bill sent (awaiting payment), paid in game, failed with the reason, or cancelled. When it is paid in game, the visit turns Paid on its own, on behalf of the system.

• Mark as paid by hand, or editing the visit (which removes the signature) before it is sent, cancels the pending bill.
• After a failure (for example “insufficient funds”), Retry the bill sends it again (you need Medical records › Retry a care bill, only shown when the game integration is on). The button doesn’t show when the outcome is uncertain, so nobody is ever charged twice.

Delete a visit

Hold the Delete visit button down (you need Medical records › Delete a visit). The visit disappears from the record and the figures, but it isn’t destroyed: it can be restored from the archives. A care bill not sent yet is cancelled.

Operative report

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Marcus Bell’s operative report, unfolded

The operative report describes a surgery. It is attached to one of the patient’s visits (10 at most per visit) and stays under medical confidentiality: it is only visible with Medical records › See medical records.

In the demo, Marcus Bell’s “Grove Street shooting, multiple wounds” visit has injuries on the chart and its operative report: exploratory laparotomy and splenectomy, by surgeon Nadia Petrova.

Writing a report

1. In Records › Medical records, search for the patient.
2. On the visit’s card, click Write an operative report. The button only shows with Medical records › Write operative reports, and disappears once the visit holds 10 reports.
3. Fill in the New operative report panel (details below). The Indication, the Lead surgeon and the Start are required.
4. If you have Medical records › Sign an operative report, the Sign now switch signs it as soon as it is saved.
5. Click Save the report.

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The operative report panel: team, times, procedures and operative site

Section	What it holds
Team and anesthesia	the Lead surgeon (a member, you by default), the Team (12 members at most, each with a free Role: assistant surgeon, scrub nurse…; Add to the team), the Anesthesia (General, Regional, Local, Sedation, No anesthesia) and the Anesthetist
Times	the Start and the End (after the start, 24 h at most); the card shows the duration, or “End not given”
Indication and diagnoses	the Indication, the Preoperative diagnosis and the Postoperative diagnosis (300 characters at most each)
Procedures performed	procedures from the Surgical procedures list (30 at most)
Operative site and findings	the same body chart as the assessment, with the same injury types and severities
Findings and disposition	the Findings, Complications, Condition leaving the OR, the Disposition (Recovery room monitoring, Admitted, Intensive care, Discharged, Transferred, Deceased) and the Follow-up instructions

The member search (surgeon, team, anesthetist) offers the members of the departments that have medical records.

Surgical procedures is a kind of reference list. Its starter pack offers fracture reduction, osteosynthesis, projectile extraction, wound debridement, suture, exploratory laparotomy, splenectomy, bowel repair, chest drain, thoracotomy, vascular repair and craniotomy; install it from the Medical department step of getting started.

Reading, signing, editing

On the visit’s card, Operative report (1) or Operative reports (2) unfolds the reports; Hide the reports folds them back. Details on a report shows all of it.

• Sign attests a report that is To sign (you need Medical records › Sign an operative report); you can sign a colleague’s.
• Edit reopens the panel. Your own report is edited with Write operative reports, a colleague’s with Medical records › Edit all operative reports. As for a visit, editing a signed report removes the signature: it must be signed again.
• History unfolds each change, before → after (“wrote the report”, “edited the report”, “signed the report”).
• Hold Delete the report down to delete it (you need Medical records › Delete a visit). It isn’t destroyed: it can be restored from the archives.

Export, issue a document

• Export, on a visit, an operative report or the medical history card, produces a PDF or an image marked “Confidential — medical secrecy” (see PDF and image export).
• Under each visit, Issued documents lists the documents drawn from that visit (medical certificate, sick note…). When your organization has templates for visits, Issue a document fills one with the visit’s data (you need Documents › Issue a document; see Documents).

Victims of a large response

For a large response (accident, fire, shooting), an operation type can show the Victims section in the Operation reports module: it is hidden by default and turned on type by type. On each victim, the Medical record button opens their record directly in this module, to record the visit.

Confidentiality and permissions

Medical records are confidential: the screen says so in its header. Only members whose rank has Medical records › See medical records, in at least one of their departments, see them. In practice, the medical department. A police officer sees nothing, neither on this screen nor on the citizen record. Medical records never show up in ⌘K search.

Permission	What it allows	Default
Medical records › See medical records	open the module, search a patient, read medical records, medical history, operative reports and logs	every rank
Medical records › Record a visit	record a visit (in a department where you have this permission)	members and up
Medical records › Edit own visits	edit a visit you recorded	members and up
Medical records › Edit all visits	edit a colleague’s visit	supervisors and up
Medical records › Sign a visit	sign a visit, yours or a colleague’s; the care bill is then sent in game	members and up
Medical records › Edit medical history	update a patient’s blood type and medical history	members and up
Medical records › Mark a bill paid	mark a visit paid or unpaid	members and up
Medical records › Retry a care bill	send a failed care bill again in game (game integration)	members and up
Medical records › Write operative reports	write an operative report and edit your own	supervisors and up
Medical records › Edit all operative reports	edit a colleague’s operative report	command
Medical records › Sign an operative report	sign a report, yours or a colleague’s	supervisors and up
Medical records › Delete a visit	archive a visit or an operative report (restorable)	supervisors and up

In the starter template, the physician rank also has Write operative reports. For an existing organization, a migration gave Write operative reports and Sign an operative report to the ranks that already edit all visits, and Edit all operative reports to those of them that also have a command permission.

Without the permission, Edit, Sign, Mark as paid or Retry the bill stays visible but locked, with a padlock and the “Restricted: …” hint naming the permission to ask for (see Permissions). New visit, Write an operative report and Delete visit don’t show at all.

The audit log keeps track of each recording, edit, signature, payment change, payment received from the game and deletion (who, when, for which patient), but never the medical content: neither the title, nor the assessment, nor the history. For an edit, it only says which sections changed (“Severity”, “Injuries”…), whether the signature dropped and, where relevant, the amount before and after. The before → after detail lives in the visit’s history, seen by the medical department only. The same goes for operative reports: the log records who wrote, edited, signed or deleted an operative report, and for which patient, never its content.

Permissions are set rank by rank: see Ranks and permissions.

The starter pack

An organization created with a medical department gets a pack ready to adapt: the Consultation, Emergency response and Hospital stay visit types with their vital signs, procedures and prices (some with a range), body zones (in anatomical order), injury types and severities, surgical procedures and the Medical history sheet. An older organization installs it from getting started, Medical department step: nothing is duplicated, only what is missing is added.