The records entry section is the section to enter new clinical events for that patient. By default it opens to a standard consultation entry screen, as this is the most commonly used. However this can be edited by clicking on your name in the top right of the screen and changing the option under "Default notes view:" to whichever option you prefer.
Standard and Re-examination
The standard and Re-examination consultations have a non-editable date field at the top. Underneath is a subjective field for entering subjective details (history) about the consultation. There is also an objective field for examination findings, a treatment field for active and passive care, and a plan field for scheduling and other items that need attention at the next visit.
Enter details as appropriate in each then click “Save” at the bottom to enter the encounter.
Records can be edited for up to 24 hours, and after that time they are locked. Edits are marked in the record with an entry like: "Edited by Matthew Holmes at Sun, 04/08/2013 13:11:06" at the bottom of the record. At the bottom right of an entry which is able to be edited there will be the text "Edit". Click this to edit.
Initial
The Initial consultation has History, Examination, Diagnosis, Prognosis, Scheduling and Treatment fields which should be self-explanatory. Click “Save” to enter the record.
Records can be edited for up to 24 hours, and after that time they are locked. Edits are marked in the record with an entry like: "Edited by Matthew Holmes at Sun, 04/08/2013 13:11:06" at the bottom of the record. At the bottom right of an entry which is able to be edited there will be the text "Edit". Click this to edit.
Open Entry
This option is a single field that you can structure however you wish.
Enter details as appropriate then click “Save” at the bottom to enter the encounter.
Records can be edited for up to 24 hours, and after that time they are locked. Edits are marked in the record with an entry like: "Edited by Matthew Holmes at Sun, 04/08/2013 13:11:06" at the bottom of the record. At the bottom right of an entry which is able to be edited there will be the text "Edit". Click this to edit.
Diagnosis
This is where you will find a list of current as well as inactive diagnoses for the patient as well as where you can enter a new diagnosis. To enter a new diagnosis type the entry in the field under “Add Diagnoses”, the click “Save”.
To make a current diagnosis inactive or vice versa, select either the “Current” or “Inactive” radio button under the diagnosis entry, then click “Update”.
Warnings and Cautions
This provides a means to flag pertinent information about the patient. Warnings are designed to be information that will impact the management of the patient. Cautions are information that may impact the management of the patient.
The current warnings and cautions are shown at the top of the tab, underneath are the fields to enter new ones, and below are listed the inactive ones for that patient. To means to add or make inactive or current are the same as that listed in the diagnosis section.
The current warnings and cautions are highlighted by an alert that shows at the top of the records section.
Addendum
This allows you to make an entry on the record of miscellaneous information. One possible use is to add information that was omitted from a clinical entry or to note a correction of an error.
Records can be edited for up to 24 hours, and after that time they are locked. Edits are marked in the record with an entry like: "Edited by Matthew Holmes at Sun, 04/08/2013 13:11:06" at the bottom of the record. At the bottom right of an entry which is able to be edited there will be the text "Edit". Click this to edit.
Report
This section is for entering reports such as x-ray reports or blood test results. Any Reports entered are displayed above the Files Uploaded (bottom right of the screen). Enter a Report by selecting "Report" from the "Select Consultation Type:" drop down list. The "Type of test:" field will show in the heading when the Report is saved. Enter the text of the report in larger text area.