The Medical tab provides designated team members with the ability to add, edit, delete, and view the Medical Evaluation and follow-up information for a particular CAC case. Access to this tab can be limited to read-only, edit/full access or none at all.

This will depend on the role granted to your account in Trak and can be configured by your CAC’s Security Officer under Administration – Roles in Trak. When you only have ‘View’ privileges for this tab, there are no text boxes or pick list options enabled on the page and all else are read-only.

The Medical tab has the different sections divided into the “Incoming Referral”, Medical Services Overview”, “Session Log/Appointments”, “Medical Exam Records”, “Outside Referrals”, “Additional Points of Contact” and the “Document Upload”.

The Save and Cancel buttons for the tab are located just below your CAC’s logo at the top left section of the Medical tab. These buttons lock and are accessible as you go down to the bottom of the page so you do not need to scroll all the way up when you want to save changes when you are editing at the bottom section of the tab.

Figure 1. “Save,” and “Cancel” buttons on the Medical Tab

The “Incoming Referral” section is used to record the agency and personnel who referred the case for medical services and the date referred.

Figure 2. “Incoming Referral” section on the Medical Tab

STEP 1: Enter Date

Start by entering the date the referral is made in the “Date” field.

STEP 2: Enter the Referring Agency

Enter the agency referring the client for treatment. Select the agency that made the referral from the “Referral Source” drop down list. The agency may be an outside agency but also may be your own agency. If the agency is not in the list, you can add/create it.

Figure 3. Referring Agency

To add a new Agency, click on the “Add” button next to the Referral Source field. A “New Agency” dialog box will appear with a list of existing agencies at the top. Check to make sure the agency you want to add is not in the list. If it is on the list, select it there and return to the Incoming Referral section. If it is not on the list, enter the agency name, address and phone number in the open fields. Click “Save” to add the new agency or “Cancel” to forego adding a new agency.

Figure 4. “New Agency” dialog box

STEP 3: Enter the Individual Making the Referral

Once the agency is selected, the Person dropdown list will be populated with available personnel from the chosen agency. Select the individual who made the referral from the “Person” drop down list.

Figure 5. Referring Person

To add a new Person, click on the “Add” button next to the Person field. The “New Personnel” dialog box will appear with a list of existing individuals associated with the agency at the top. Check to make sure the person you want to add is not in the list. If they are on the list, click cancel to return to the Incoming Referral section and select them from the Person drop down box. If the individual does not appear in the list, enter the individual’s name, credentials, job title, email address and phone number, if known. First and last names are required. Click “Save” to add the new person or “Cancel” to forego adding a new person.

Figure 6. “New Personnel” dialog box

The medical service overview section is used to record key information about who provided the medical services and the date when all services were completed.

Figure 7. Medical Services Overview section

STEP 1: Enter the Medical Case Number

Enter the Medical Case number, if applicable.

STEP 2: Enter the Primary Care Provider

Enter the client’s Primary Care Provider, if known.

STEP 3: Enter the Provider Agency

Enter the agency providing the medical evaluation. If the Agency is not listed, click “Add.”

To add a new Agency, click on the “Add” button next to the Referral Source field. A “New Agency” dialog box will appear with a list of existing agencies at the top. Check to make sure the agency you want to add is not in the list. If it is on the list, select it there and return to the Incoming Referral section. If it is not on the list, enter the agency name, address and phone number in the open fields. Click “Save” to add the new agency or “Cancel” to forego adding a new agency.

Figure 8. “New Agency” dialog box

STEP 4: Enter the Individual Providing Medical Services

Select the “Person” providing the medical evaluation from the Person pick list. This list will be populated with the available personnel from the chosen Provider Agency. If the person is not in the list, click “Add.”

To add a new Person, click on the “Add” button next to the Person field. A “New Person” dialog box will appear with a list of existing individuals associated with the agency. Check to make sure the person you want to add is not in the list. If they are on the list, click cancel to return the Incoming Referral section and select them from the Person drop down box. If the individual does not appear in the list, enter the individual’s name, credentials, job title, email address and phone number, if known. First and last names are required. Click “Save” to add the new person or “Cancel”

to forego adding a new person.

Figure 9. “New Personnel” dialog box

STEP 5: Enter Peer Review Information

Enter the “Date” of Peer Review and type in the name of the “Reviewer” who conducted the peer review, if applicable.

Figure 10. Peer Review data fields

STEP 6: Custom Fields

Enter information into any custom fields your CAC may have added to the Medical Services Overview section. There are up to 9 custom fields available for use by each CAC in this section. When not in use, these fields are hidden.

Figure 11. Adding “Custom Fields” in the Medical Services Overview section

The session log is used to schedule and record the details of each medical visit, including attempted exams as well as completed exams and follow-up visits.

To add an entry into the Session Log/Appointments table, click on the “Add New Session Log” button.

Figure 12. “Add New Session Log” on the Session Log / Appointments table

This will open the Edit dialog box for adding a new session log. The Date field defaults to today’s date and note that the Session ID is set to 0. Once you have saved the session log, Trak automatically assigns a session ID for this session log which you will need if you want to run the Medical Report from the Reports – Management on the left-hand side menu of Trak. See the help file for Management Reports for more information.

Figure 13. Session ID on the session log

STEP 1: Schedule an Appointment

To schedule a future appointment, enter the date in the “Date” field, as well as, anticipated start and end times in the “Start” and “End” fields. Select “Scheduled” from the “Status” drop down list.

The Prep field provides an opportunity to document preparation time by the provider for the exam.

Figure 14. “Date,” “Start” and “End” times, Prep and appointment “Status”

STEP 2: Enter Appointment Details

Select the appropriate “Provider Agency” and “Provider Personnel” who will conduct the medical evaluation/session from the dropdown menus. If you need to add a new Provider Agency and a new Provider Personnel, just click on the “Add” buttons beside these fields and you will get the “New Agency” and “New Personnel” dialog boxes.

Select “Onsite” or “Offsite” from the “Location” dropdown.

Type in who is bringing the client to appointment in the “Brought By” text box.

Select the type of session from the “Type” dropdown list.

If applicable, specify funding source by selecting an option from the “Funding Source” dropdown list. The Funding Source options are specific to each CAC. Contact your CAC Administrator/Security Officer to add to, or to modify this list.

Figure 15. “Providing Agency,” Provider,” Location” “Brought by,” “Type” and “Funding Source” fields

Click “Update” to save the record. Click “Cancel” to forego adding a new record.

There are also three custom fields available within the Medical session.

Figure 16. Custom Fields

STEP 3: Review and Edit Appointments

Once a scheduled appointment has been attended or the scheduled appointment date has passed, select the “Edit” button to update the appointment record. Attended appointments (or any appointment on the list) can be updated at any time by selecting the Edit button. Note that your assigned role in Trak must have Update rights for the Medical General and Medical Details sections to be able to see the Edit and Delete buttons.

Once changes are made, select “Update” to save your changes and return to the list of session logs.

Figure 17. “Edit” and “Delete” buttons in the session log

The Session Log/Appointments section in the Medical tab will also allow a user to view more details about the client’s medical history, medical evaluation and other pertinent medical data. Once you have saved a session log, new functionalities will be available. The “View Details” and “View Historic” buttons are now accessible and you will be able to add observers to the session by clicking on the “Add New Observer” button. Please see the Medical Details help file for a more comprehensive set of information for this section.

Figure 18. “View Details,” “View Historic,” and “Add New Observer” in the session details To delete an appointment record, select the “Delete” button. A dialog box will come up to ask you to confirm if you want to delete the session log. It is important to know that if you decide to delete a session log, it will also delete all the medical evaluation details that were recorded in that session.

Figure 19. “Delete” confirmation dialog box Select “OK” to delete or “Cancel” to forego deleting the record.

STEP 4: Print Medical Report

If you need a hard copy of the details in all the subtabs in the Medical tab, you can use the “Print Medical Report” button from the Session Log/Appointments section. This will give you a clinical report with all the findings/results noted during the selected session. This report includes all data recorded in the different sub-tabs for the Medical tab. Previously, these sub-tabs can be accessed from the Medical tab. With the Trak upgrade, the sub-tabs can be accessed by clicking on the “View Details” button You need to have at least View access to the Medical Details to be able to use this feature.

NOTE: This option is also available by choosing Case Medical Report in Reports – Management on the lefthand side menu of Trak. You will need to provide the specific case number and session ID for which you want to run the report for.

Figure 20. “Print Medical Report” button

Sample of the report:

Figure 21. Sample Medical Report

STEP 4: Copy to Co-Victim

If on the People Tab individuals are entered with the role of Co-Victim the Copy to Co-Victim button will become available.

Figure 22. Copy to Co-Victim Button

The below information will copy to co-victims on the case.

Figure 23: Copy to Co-Victim information

STEP 5: Reminders

Scheduled sessions can also include Notify Staff and Notify Clients buttons. These buttons allow the scheduled session information to be shared with MDT members or Families.

See end of page for a video on appointment reminders.

Figure 24. Reminder Buttons

The medical exam records table is used to record what type of medical records you have for the case and where they are stored.

Figure 25. Medical exam records table

STEP 1: Add a New Medical Exam Record

Click “Add New Record” and select the “Type” of record from the drop down list, type in the “Storage Location,” and enter a “Media Number” to catalogue the record.

Click “Update” to add the record or “Cancel” to forego adding the record.

STEP 2: Edit or Delete a Medical Exam Record

To make changes to a medical exam record, select the “Edit” button next to the record in the table.

Once changes are made, select “Update” to save your changes and return to the list.

To delete a record, select the “Delete” button. A pop up box will ask, “Are you sure you want to delete this record?”

Select “OK” to delete or “Cancel” to forego deleting the record.

Figure 26. “Edit” and “Delete” buttons in the medical exam records table

The outside referrals table provides CACs the ability to keep additional information about services a child/family might need that are outside of the scope of services provided by the CAC or the MDT.

The pick list is customizable to meet your community needs.

Figure 27. Outside referrals table

STEP 1: Add an Outside Referral

Click “Add New Referral” and a pop up box will appear.

Enter the date of the referral in the “Date” field, select the agency the referral was made to in the “Referral To” drop down list and enter any comments, if applicable, in the “Comment” box.

Click “Update” to add the referral or “Cancel” to forego adding the referral.

STEP 2: Edit or Delete an Outside Referral

To make changes to a referral record, select the “Edit” button next to the record in the table.

Once changes are made, select “Update” to save your changes and to return to the list.

To delete a record, select the “Delete” button. A pop up box will ask, “Are you sure you want to delete this record?” Select “OK” to delete or “Cancel” to forego deleting the record.

Figure 28. “Edit” and “Delete” buttons in the outside referrals table

The Additional Points of Contact is a table that provides a place to record information about other people who may be contacted throughout the course of the investigation and follow-up services. All of the fields in the table are text fields and all are optional.

Figure 29. Additional points of contact table

STEP 1: Add a New Point of Contact

Select “Add a New Point of Contact” and a pop up box will appear. Enter information into the “Agency,” “Name,” “Phone Number,” and “Email” fields.

Click “Update” to add the contact or “Cancel” to forego adding the contact.

NOTE: All of the fields in the table are text fields and all are optional. To enter the phone number you can enter 7 or 10 consecutive numbers and the system will format the number like this:

(xxx) xxx-xxxx. To add an extension, enter an “x” immediately after the last number and then up to a 4 digit extension.

STEP 2: Edit or Delete a Point of Contact

To make changes to a point of contact record, select the “Edit” button next to the record in the table.

Once changes are made, select “Update” to save your changes and return to the list.

To delete a record, select the “Delete” button. A pop up box will ask, “Are you sure you want to delete this record?” Select “OK” to delete or “Cancel” to forego deleting the record.

Figure 30. “Edit” and “Delete” buttons in the additional points of contact table

To upload documents related to the information entered on the Medical Tab, scroll down to the “Document Upload” section towards the bottom of the page. Files uploaded in the main/general Medical tab are not available in the document upload section of the subtabs. Please see the Medical Details help file for more information.

Refer to the “Document Upload” help file for details on uploading and managing documents.

NOTE: NCA does not recommend the storage of evidentiary documents as part of this case record. Any copies of evidentiary materials should be retained by the appropriate law enforcement and prosecution partners.

The table below contains information about the data fields on the Medical tab. Red data fields are

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