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Patient Information fields
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Facility
Automatically displays a list of Facilities with a radio button preceding each Facility. Initially, no radio buttons are selected. Allows user to select a Facility by clicking on a radio button displayed immediately before the name of the Facility. User may only select one Facility. Once selected, Facility can only be deselected by clicking on another Facility in the list (or on an item in the list labeled “No Facility” or “Select a Facility”).
Here’s an example of a list of Facilities in Form Builder Preview-mode, as the Form user would see it.
There are only limited options for configuring the Facility selection list in Form Builder Edit-mode.
The list of Facilities itself is set up and maintained in Practice > Administrative > Facilities
Full Name
Automatically displays Full Name of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Full Name field as it would appear to the Form user when a patient is selected:
The Full Name field is configured in Form Builder, Edit-mode.
Address
Automatically displays Address of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Address field as it would appear to the Form user when a patient is selected:
The Address field is configured in Form Builder, Edit-mode.
Admit Facility
Automatically displays Admit Facility of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Admit Facility field as it would appear to the Form user when a patient is selected: In the case of an actual patient, the specific name of the Facility where the patient was admitted would be displayed.
The Admit Facility field is configured in Form Builder, Edit-mode.
Admit Date
Automatically displays Admit Date of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Admit Date field as it would appear to the Form user when a patient is selected:
The Admit Date field is configured in Form Builder, Edit-mode.
Age
Automatically displays Age of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Age field as it would appear to the Form user when a patient is selected:
The Age field is configured in Form Builder, Edit-mode.
DOB
Automatically displays Date of Birth (DOB) of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The DOB field as it would appear to the Form user when a patient is selected:
The DOB field is configured in Form Builder, Edit-mode.
Phone Numbers
Automatically displays Phone Numbers of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Phone Numbers field as it would appear to the Form user when a patient is selected:
The Phone Numbers field is configured in Form Builder, Edit-mode.
S.S. #
Automatically displays Social Security Number (S.S. #) of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The S.S. # field as it would appear to the Form user when a patient is selected:
The S.S. # field is configured in Form Builder, Edit-mode.
Add Patient Image
Automatically displays Patient Image (photograph, head shot) of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Add Patient Image field as it would appear to the Form user when a patient is selected:
If this were an actual patient, their photograph would appear if it has been electronically recorded in their chart at registration.
The Add Patient Image field is configured in Form Builder, Edit-mode.
Marital Status
Automatically displays Marital Status of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Marital Status field as it would appear to the Form user when a patient is selected:
The Marital Status Image field is configured in Form Builder, Edit-mode.
Gender
Automatically displays Gender of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Gender field as it would appear to the Form user when a patient is selected:
The Gender field is configured in Form Builder, Edit-mode.
Telephone Number
Automatically displays Phone Number of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Telephone Number field as it would appear to the Form user when a patient is selected:
The Telephone Number field is configured in Form Builder, Edit-mode.
Race
Automatically displays Race of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten on Forms. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Race field as it would appear to the Form user when a patient is selected:
The Race field is configured in Form Builder, Edit-mode.
Ethnicity
Automatically displays Ethnicity of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Ethnicity field as it would appear to the Form user when a patient is selected:
The Ethnicity field is configured in Form Builder, Edit-mode.
Discharge Date
Automatically displays Discharge Date of currently selected patient. Information is drawn from the Patient Chart, which is created at registration, and cannot be deleted, altered or overwritten from within the Form. Changes to this information can only be made within the Patient Chart, which is not a Form.
The Discharge Date field as it would appear to the Form user when a patient is selected:
The Discharge Date field is configured in Form Builder, Edit-mode.
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types allows the user to auto-populate patients data in the field, information like name, DOB and the like from the patient's demographics into the form.
The following are the basic field types:
| Fields | Description |
|---|---|
| Facility | Displays a list of facilities in the organization. |
| Provider / User | Displays a list of users in the organization. |
| Full Name | Displays patients full name. |
| PID | Displays Patients unique ID. |
| Service Date | Displays the date service date of an encounter, date when the patient meets the provider/clinician. |
| Address | Displays residentials address of the patient. |
| Admit Facility | Displays the name of the facility where a patient was admitted. |
| Admit Date | Displays the date when the patient was admitted in the facility. |
| Age | Displays the age of the patient in years and days. |
| DOB | Displays the date of birth of the patient. |
| Phone Numbers | Displays the patients home and mobile numbers. |
| S.S # | Displays the patients social security number. |
| Add Patients Image | Displays the patients display photograph. |
| Marital Status | Displays the patients marital status. |
| Gender | Displays the patients gender (Male or female). |
| Telephone Number | Displays the patients cell number. |
| Insurance | Displays the patients primary insurance name. |
| Vital | Displays vitals information of the patient. |
| Race | Displays patients race, region where the patient belong to. |
| Ethnicity | Displays the patients culture/Nation. |
| Discharged Date | Displays the date when the patient was discharged from the facility. |
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