How to Document Clinical Findings

How to Document Clinical Findings

The Clinical Record step is where you document what happened during the consultation. It uses a POMR (Problem-Oriented Medical Record) structure with Record and Action sections.

Record Section

The Record section contains buttons for documenting clinical findings. Each button opens a text area for free-form notes, and many also support linking structured clinical data.

The available Record buttons are:

Button	Purpose
History	Patient-reported symptoms, timeline, chief complaint
Family History	Family medical history and genetic factors
Social	Social circumstances, lifestyle, environmental factors
Allergies	Known allergies and adverse reactions
Examination	Clinical observations, measurements, vital signs
Procedures	Clinical procedures performed or planned
Document	Linked documents and correspondence
Immunisation	Notes about immunisations administered
Comment	Clinical reasoning, assessment notes, treatment rationale

The order of these buttons can be customised per organisation.

Working with Record Sections

Each section supports:

• Free-text notes with basic formatting
• Slash commands - type / to search and insert common clinical items
• Structured data linking - observations, allergies, procedures, and other clinical data can be linked directly from the relevant section
• Collapsible sections - collapse sections you are not using to reduce clutter
• Removable sections - remove sections that are not relevant to this consultation

Action Section

The Action section contains buttons for creating structured clinical data that is linked to the consultation. See the article on consultation actions for full details.

Per-Problem Documentation

If you have selected problems, each problem gets its own tab. Documentation in Record sections is associated with the active problem tab. See the article on adding problems and diagnoses for details on problem tabs.

Tip: Use the Comment section for your clinical reasoning and assessment. This is where you explain why you made certain decisions, which is valuable for audit and continuity of care.