The medical case (EHR)

What is a medical case?

A medical case is a digital health record (EHR) that stores all the clinical information for a single patient visit or condition. Think of it as a folder that holds:

• The reason for the visit (chief complaint)
• What the doctor found during examination (history and physical examination)
• Test results and imaging (labs, X-rays, ultrasound, etc.)
• Diagnosis and treatment plan
• Prescriptions and medications given
• Procedures performed
• Notes and follow-up instructions

Why it matters

In a busy clinic or hospital, a complete medical case ensures nothing is forgotten. When a patient returns, a doctor can quickly see their past visits, what treatments worked, and any ongoing conditions. This improves care quality, reduces medical errors, and helps doctors make informed decisions.

Medical cases also create an audit trail—a legal record of what happened to the patient and when. This is important for patient safety, research, and accountability.

How medical cases work in Usystems

Each patient can have one or more medical cases. A case is typically opened when:

• A patient arrives for an outpatient visit (clinic consultation)
• A patient is admitted to a ward (inpatient stay)
• A patient needs a specific procedure or surgery

Once created, the medical case collects all data related to that episode of care. Different departments (doctors, nurses, labs, pharmacy) can view and add to the same case, so everyone stays informed.

Case components

• Patient demographics: name, age, contact info
• Chief complaint: why the patient came
• History and examination findings: vital signs, physical exam notes, patient symptoms
• Diagnostic tests: lab results, imaging reports, special investigations
• Clinical assessment: doctor's diagnosis and differential diagnosis
• Treatment plan: medications, procedures, referrals, follow-up
• Progress notes: updates on how the patient is responding
• Medical specialties: some cases are flagged for specific departments (Orthopedics, Pediatrics, ENT, etc.)

Where you see medical cases

• Medical cases list: Go to Clinical → Medical Cases to find all patient cases. Open in Usystems
• Patient profile: Click a patient's name in Patients to see their case history. Open in Usystems
• Departments: Different wards or specialties (Orthopedics, Emergency, etc.) may have their own view of active cases.

Special features

Specialty cases: Cases can be linked to a medical specialty (Orthopedics, Emergency, Pediatrics, ENT) so that the right team sees the relevant information.

Follow-up and referrals: A doctor can schedule follow-up visits or refer a patient to another department, creating a linked sequence of cases.

Confidentiality: Access to a medical case is restricted by role and permission—only authorized staff can view patient health information.

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