Adding Clinical Data

  1. Open a patient record. See - Selecting Patients - Overview.
  2. To record data an Encounter must be open. See - Adding an Encounter.

  3. 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.
  4. 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.
  5. 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.
  6. Select the Save button to add the entry to the current encounter.