Clinical Record

Viewing and managing the patient clinical record

Patient Record Overview

Navigating the patient record and using the summary view

Navigating the Patient RecordVideo

Understand how the patient record is structured, including the main tabs, clinical record sidebar, and patient sidebar.

Using the Patient SummaryVideo

Use the Summary tab for quick actions, view draft consultations, recent activity, and open tasks at a glance.

Problems & Allergies

Record and manage patient problems, diagnoses, and allergies

Managing Problems and DiagnosesVideo

Add, edit, and track patient problems with SNOMED coding, significance levels, and status management.

Recording AllergiesVideo

Record drug and non-drug allergies with criticality levels, reactions, and NKDA status.

Medications

Manage patient medications, dosages, and medication lifecycle

Locking the prescriber to the signed-in clinician

Control whether prescribing and reauthorising attribute to the signed-in clinician or allow free choice.

Managing MedicationsVideo

View and manage a patient's acute and repeat medications, including adding, pausing, stopping, and reauthorising.

Issuing a PrescriptionVideo

Create a prescription from issued medications, review patient details, select a prescriber and issue method, and send or save the prescription.

Prescribing Safety Alerts

Understand clinical decision support alerts during medication issuance, including allergy warnings, interactions, and how to override when clinically appropriate.

Reauthorising, Changing, and Stopping MedicationsVideo

Extend repeat medications, change medication types, and stop medications with a documented clinical reason.

Observations & Investigations

Record vital signs and view lab results and trends

Recording ObservationsVideo

Record vital signs and clinical measurements such as blood pressure, heart rate, temperature, weight, and height.

Referrals, Care History & Episodes

Manage referrals, view the clinical timeline, and track episodes of care

Managing ReferralsVideo

Create and track referrals to other services with priority levels, status tracking, and linked documents.

Creating a ReferralVideo

Create a referral to a specialist or service with SNOMED-coded specialties, contact selection, clinical reasons, and priority.

Care History and EpisodesVideo

View the chronological clinical timeline and manage episodes of care for patient pathways.

ScanCom Imaging Referrals

Book imaging referrals through ScanCom with modality selection, safety screening, and provider booking.

Pathology & Labs

Lab test ordering, results, and filing