Adding Clinical Data
- Open a patient record. See - Selecting Patients - Overview.
- To record data an Encounter must be open. See - Adding an Encounter.
- Enter the keyword in the dynamic data entry bar.
- You can record a drug, immunisation or clinical term using this bar.
- Three characters are needed, items are returned as you type.
- A single letter will trigger a common observation quick entry. See - Common Observations.
- You can search the record during an Encounter. See Searching the Patient's Record.
- Select the term from the list.
The relevant data entry form displays.
If searching for a clinical term the most likely form to display is medical history, however if results match on a term with a specific form, this is automatically displayed with the associated data selection boxes eg the immunisation add form has stage and batch number boxes.
- Complete the form as required.
- Description - The chosen clinical term. You can change by searching an appropriate term if required.
- Priority - The default priority is 3 but you can select from 0-9.
- Episode type - Select from none, first ever, new event, continuing or other.
- Notes - Enter supporting free text information as required.
Select the Save button to add the entry to the current encounter.