Adding Clinical Terms

1. Open a patient record. See - Searching for Patients.
2. To record data an Encounter must be open. See - Open an Encounter.
3. Enter the keyword in the dynamic data entry bar. You can record a drug or clinical term using this form.
   A single letter will trigger a common observation quick entry, or 3 characters are needed for either a drug or clinical term.
   See - Adding Common Observations.
4. Select the term from the list.
5. The relevant data entry form displays. If searching for a clinical term the most likely form to display is medical history but if results match on a term with a specific form, this is automatically displays with the associated data selection boxes eg the immunisation add form has stage and batch number boxes.

   

6. 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.
7. Tap Add to save.
8. When the consultation is completed, from the Current Encounter screen, tap Done to save your consultation.
   Note - If you do not do this the patient record is added to the list and data is not transferred back to the practice system.
   Open encounters are saved on your device and are not available from any other setting, they are automatically deleted after 30 days.