OpenEMR Clinician Guide

OpenEMR is the electronic medical record (EMR) system used by clinicians in the Med-SEAL Suite. It handles patient management, clinical documentation, prescribing, scheduling, and billing.

Accessing OpenEMR

Navigate to your OpenEMR instance (default: http://localhost:8081) and log in with your SSO credentials. First-time users should see the main clinical dashboard.

Dashboard Overview

After login, the OpenEMR dashboard displays:

  • Messages – internal messages and alerts from staff

  • Reminder mail – upcoming patient tasks

  • Upcoming appointments – today’s and tomorrow’s schedule

  • Patient finder – quick search by name or ID

Patient Management

Searching for a Patient

  1. From the top menu, click Patient > Patient Finder.

  2. Enter the patient’s name, date of birth, or patient ID.

  3. Click Search, then select the patient from the results list.

Registering a New Patient

  1. Click Patient > New/Search.

  2. Click New Patient.

  3. Fill in the Demographics tab: name, date of birth, gender, contact details.

  4. Click Create New Patient.

Clinical Documentation

Recording an Encounter

  1. Open a patient’s chart.

  2. Click Encounters > New Encounter.

  3. Select the Encounter date, Facility, and Provider.

  4. Click Save.

  5. Add encounter notes in the SOAP or History & Physical form.

Ordering Labs and Procedures

  1. Inside an open encounter, click Clinical > Procedures.

  2. Select the procedure type and enter order details.

  3. Click Save and Transmit.

Prescribing Medications

  1. Open the patient’s chart and navigate to Prescriptions.

  2. Click Add.

  3. Search for the drug by name or NDC code.

  4. Set dosage, frequency, quantity, and refills.

  5. Click Save.

The prescription is saved to the patient’s FHIR record via the Medplum sync.

Scheduling Appointments

  1. Click Calendar in the top menu.

  2. Click an available time slot for the provider.

  3. Search for and select the patient.

  4. Choose appointment type and add notes.

  5. Click Save.

A FHIR Appointment resource is created automatically and visible in the Patient Portal.

AI Clinical Brief (Pre-Visit Summary)

Before a scheduled appointment the AI Insight Synthesis Agent (A5) generates a Pre-Visit Summary – a structured brief covering:

  • Medication adherence over the past 30 days

  • Biometric trends (blood pressure, glucose, weight)

  • Patient-Reported Outcomes (PRO scores)

  • Open flags and escalation alerts

  • AI-suggested talking points

To view the brief, open the patient’s chart and click AI Insights in the left sidebar.

Billing and Coding

  1. After documenting an encounter, click Billing > Add New Bill.

  2. Assign ICD-10 diagnosis codes and CPT procedure codes.

  3. Submit the claim or save for later review.

Logging Out

Click your username in the top-right corner and select Logout. For shared workstations, always log out after each session.