Clinical Records

Overview

DataMed’s clinical records system provides a unified view of all patient clinical data, organized by admission cycle (Ingreso). Each type of clinical exam is tracked separately while maintaining relationships to the patient’s active treatment cycle.

All clinical records are automatically associated with the patient’s active Ingreso. When a new cycle begins, previous records are preserved but kept separate.

Clinical Record Types

The system tracks seven distinct types of clinical examinations and interventions:

Polysomnography

Basal and titration sleep studies with IAH tracking

Technical Monitoring

CPAP/BiPAP usage data and residual apnea tracking

Nutrition

Nutritional status, dietary habits, and caffeine intake

Psychology

Beck inventories (depression, anxiety) and Athens scale

Pulmonology

Specialist consultations and respiratory assessments

Medical Equipment

CPAP/BiPAP device and mask assignments

Follow-up Notes

Adaptation tracking and patient contact notes

Accessing Clinical Records

Navigate to Patient List

Go to Patients → Patient List from the main menu

Select Patient

Click on the patient name to open their detail view

Access Clinical Records

Click the Clinical History or Historia Clínica button to view all clinical records for the active admission

The clinical record view only displays data for the active Ingreso. This ensures clinical staff see relevant current-cycle data without confusion from previous cycles.

Polysomnography Studies

Sleep studies form the foundation of sleep apnea diagnosis and treatment monitoring.

Baseline Polysomnography (PSG Basal)

Overview
Registering a Basal PSG
Severity Classification

The baseline study establishes the patient’s sleep apnea severity before treatment:Key Metrics:

IAH (Apnea-Hypopnea Index): Events per hour
IDO (Oxygen Desaturation Index)
Efficiency: Sleep efficiency percentage
Severity: LEVE, MODERADA, GRAVE, NORMAL

Access Registration Form

From the clinical record view, click Register Basal PSG

Enter Study Data

Fill in the baseline study metrics:

# Model structure
fecha_basal: DateField
iah: Decimal(5,2)  # Apnea-Hypopnea Index
severidad_apnea: Choice[LEVE, MODERADA, GRAVE, NORMAL]
ido: Decimal(5,2)  # Oxygen Desaturation Index
eficiencia: Decimal(5,2)  # Sleep efficiency

Save and Link

The system automatically:

Associates the study with the active Ingreso
Records the registering user
Timestamps the entry

IAH Range	Severity	Treatment Priority
< 5	NORMAL	Monitoring only
5-15	LEVE	Conservative therapy
15-30	MODERADA	CPAP recommended
> 30	GRAVE	CPAP/BiPAP required

Titration Polysomnography (PSG Titulación)

Titration studies determine optimal CPAP/BiPAP pressure settings:

Titration Study Fields

class PolisomnografiaTitulacion(models.Model):
    fecha_titulacion: DateField
    
    # Ventilator settings
    tipo_titulacion: Choice["CPAP", "BPAP", "BPAP ST"]
    presion_ipap: Decimal(5,2)  # Inspiratory pressure
    presion_epap: Decimal(5,2)  # Expiratory pressure (BiPAP only)
    frecuencia_respiratoria: Integer  # Respiratory rate (BiPAP ST)
    
    # Mask configuration
    tipo_mascara: Choice["PILLOW NASAL", "NASAL", "ORONASAL"]
    talla_mascara: Choice["SMALL", "MEDIUM", "LARGE"]

Pressure Settings by Mode:

CPAP: Single pressure (IPAP only)
BiPAP: Dual pressure (IPAP + EPAP)
BiPAP ST: Dual pressure + backup rate

Technical Monitoring (Adaptación)

Monitoring sessions track patient adherence and treatment effectiveness:

Navigate to Monitoring Form

Click Register Adaptation from the clinical record view

Complete Technical Data

The form includes two tabs:

Technical Data
Contact Notes

Usage Metrics:

Daily usage percentage
Days with ≥4 hours usage
Average daily usage hours

Clinical Effectiveness:

Baseline hypopnea (auto-filled from PSG Basal)
Residual hypopnea (current)
Correction percentage (auto-calculated)

Equipment Settings:

Ventilator mode (CPAP/BiPAP/BiPAP ST)
Pressure settings (IPAP/EPAP)
Respiratory rate (if applicable)
Mask type and size
Average EtCO2

Auto-filled Baseline Value

The system automatically retrieves the IAH from the most recent basal PSG:

# Baseline value auto-fill logic
psg = PolisomnografiaBasal.objects.filter(
    ingreso=ingreso_actual
).last()
valor_basal = psg.iah if psg else 0

The correction percentage is calculated as: ((Basal - Residual) / Basal) × 100A correction rate ≥70% indicates effective therapy.

Psychology Sessions

Psychological assessments use standardized instruments:

Beck Depression

Score range: 0-63Higher scores indicate more severe depression symptoms

Beck Anxiety

Score range: 0-63Measures anxiety symptom severity

Athens Insomnia

Score range: 0-24Scores ≥6 suggest insomnia

Registering Psychology Data

# Model structure
class Psicologia(models.Model):
    ingreso: ForeignKey(Ingreso)
    inventario_depre_beck: Integer  # 0-63
    inventario_ansiedad_beck: Integer  # 0-63
    escala_atenas: Integer  # 0-24
    registrado_por: ForeignKey(User)
    created_at: DateTimeField(auto_now_add=True)

Interpretation Guidelines

Beck Depression Inventory:

0-13: Minimal depression
14-19: Mild depression
20-28: Moderate depression
29-63: Severe depression

Beck Anxiety Inventory:

0-7: Minimal anxiety
8-15: Mild anxiety
16-25: Moderate anxiety
26-63: Severe anxiety

Athens Insomnia Scale:

< 6: No clinically significant insomnia
≥ 6: Probable insomnia disorder

Nutrition Sessions

Nutritional assessments track metabolic health and dietary factors affecting sleep:

Fields
BMI Classification
Sleep Impact Factors

class Nutricion(models.Model):
    estado_nutricional: Choice[
        "DESNUTRICIÓN",
        "EUTRÓFICO",
        "SOBREPESO",
        "OBESIDAD I",
        "OBESIDAD II",
        "OBESIDAD III"
    ]
    carbohidratos_pct: Decimal(5,2)  # Carb % of diet
    rumiacion: Choice["SI", "NO"]  # Nighttime eating
    cafeina: Decimal(5,2)  # Daily caffeine (mg)

The nutritional status corresponds to BMI ranges:

Status	BMI Range	Clinical Significance
DESNUTRICIÓN	< 18.5	Underweight
EUTRÓFICO	18.5-24.9	Normal weight
SOBREPESO	25-29.9	Overweight
OBESIDAD I	30-34.9	Class I obesity
OBESIDAD II	35-39.9	Class II obesity
OBESIDAD III	≥ 40	Class III obesity

Pulmonology Consultations

Specialist consultations are tracked with minimal structured data:

class Neumologia(models.Model):
    fecha_consulta: DateField
    medico_tratante: CharField(100)
    especialidad: CharField(200)
    # Additional notes typically in clinical narrative

Pulmonology records serve as timestamps for specialist involvement. Detailed consultation notes are typically maintained in external clinical notes or physical records.

Medical Equipment Assignment

Tracking CPAP/BiPAP equipment assigned to patients:

Access Equipment Form

Click Register Medical Equipment from the clinical record view

Complete Equipment Details

class EquipoMedico(models.Model):
    # Mask configuration
    tipo_mascara_eq_medico: Choice["PILLOW NASAL", "NASAL", "ORONASAL"]
    referencia_mascara: CharField(100)
    talla_mascara: Choice["SMALL", "MEDIUM", "LARGE"]
    
    # Device information
    marca_equipo: Choice["BMC", "RESMED", "PHILIPS RESPIRONICS", ...]
    serial_equipo: CharField(100)  # Unique device identifier
    modo_ventilatorio: Choice["CPAP", "BiPAP", "BiPAP ST"]

Track Device Assignment

Equipment records include:

Serial number for inventory tracking
Assignment timestamp
Associated user who assigned equipment

Supported Equipment Brands

BMC: Budget-friendly Chinese manufacturer
ResMed: Premium Australian devices
Philips Respironics: High-end with recall history
Sefan: Regional brand
Resvent: Mid-range option
Curative: Local distributor brand
Prisma: Specialty devices
DeVilbiss: Legacy brand

Clinical Record View

The unified clinical record view displays all exam types in chronological order:

Data Organization

# View logic for active cycle only
ingreso_actual = patient.ingresos.filter(estado='ACTIVO').first()

if ingreso_actual:
    monitoreos = Monitoreo.objects.filter(
        ingreso=ingreso_actual
    ).order_by('-id')
    sesiones_psicologia = Psicologia.objects.filter(
        ingreso=ingreso_actual
    ).order_by('-id')
    # ... similar for all exam types

Critical Design Principle: By filtering all clinical records by the active Ingreso, the system ensures that when a new 18-month cycle begins, staff see a clean slate without confusion from previous cycle data.

Audit Trail

All clinical records include automatic audit fields:

Field	Type	Purpose
`ingreso`	ForeignKey	Links to specific admission cycle
`registrado_por`	ForeignKey(User)	User who created the record
`created_at`	DateTimeField	Timestamp of record creation

Audit Query Example

To find all records created by a specific user:

# Find all monitoring records by user
user_records = Monitoreo.objects.filter(
    registrado_por=request.user
).select_related('ingreso__paciente')

Best Practices

Always register baseline PSG first

The baseline polysomnography should be the first clinical record entered, as its IAH value is referenced by monitoring sessions for correction percentage calculation.

Complete titration before equipment assignment

Perform and record the titration study before assigning CPAP/BiPAP equipment to ensure correct pressure settings are documented.

Regular monitoring schedule

Schedule technical monitoring at:

Week 2: Initial adaptation check
Month 1: First monthly review
Months 3, 6, 9, 12, 15, 18: Quarterly reviews

Document equipment serial numbers

Always record device serial numbers for:

Warranty tracking
Recall management
Inventory control
Insurance documentation

Next Steps

Exam Tracking

Learn how to monitor exam completion across capita months

Follow-Up System

Understand the follow-up tracking and alert system

Get Started

Core Features

User Guides

Medical Modules

Clinical Records

Overview

Clinical Record Types

Polysomnography

Technical Monitoring

Nutrition

Psychology

Pulmonology

Medical Equipment

Follow-up Notes

Accessing Clinical Records

Polysomnography Studies

Baseline Polysomnography (PSG Basal)

Titration Polysomnography (PSG Titulación)

Technical Monitoring (Adaptación)

Psychology Sessions

Beck Depression

Beck Anxiety

Athens Insomnia

Registering Psychology Data

Nutrition Sessions

Pulmonology Consultations

Medical Equipment Assignment

Clinical Record View

Data Organization

Audit Trail

Best Practices

Next Steps

Exam Tracking

Follow-Up System

Build docs developers (and LLMs) love

Get Started

Core Features

User Guides

Medical Modules

Documentation Index

​Overview

​Clinical Record Types

Polysomnography

Technical Monitoring

Nutrition

Psychology

Pulmonology

Medical Equipment

Follow-up Notes

​Accessing Clinical Records

​Polysomnography Studies

​Baseline Polysomnography (PSG Basal)

​Titration Polysomnography (PSG Titulación)

​Technical Monitoring (Adaptación)

​Psychology Sessions

Beck Depression

Beck Anxiety

Athens Insomnia

​Registering Psychology Data

​Nutrition Sessions

​Pulmonology Consultations

​Medical Equipment Assignment

​Clinical Record View

​Data Organization

​Audit Trail

​Best Practices

​Next Steps

Exam Tracking

Follow-Up System

Build docs developers (and LLMs) love

Overview

Clinical Record Types

Accessing Clinical Records

Polysomnography Studies

Baseline Polysomnography (PSG Basal)

Titration Polysomnography (PSG Titulación)

Technical Monitoring (Adaptación)

Psychology Sessions

Registering Psychology Data

Nutrition Sessions

Pulmonology Consultations

Medical Equipment Assignment

Clinical Record View

Data Organization

Audit Trail

Best Practices

Next Steps