Adding Clinical Data
- From Vision Anywhere, select the patient required.
- Select New Encounter .
- Enter a keyword in the dynamic search bar:
The keyword can be to:
- Record a drug, immunisation or clinical term
- Trigger a template or calculator.
A single letter triggers a common observation quick entry, three letters or more returns a pick list of clinical terms
There are some short cuts, for example, to quickly record a blood pressure, enter 120/80 and select blood pressure reading.
- Select the term required from the list and the relevant data entry form displays.Note - SNOMED CT Preferred Terms are highlighted with a PT indicator .Note - England Only - QOF compliant terms are highlighted with a QOF indicator.
- Complete the form as appropriate:
- Description - Defaults to the term selected. You can change by searching an alternative term if required.
- Priority - Defaults to 3, but you can select from 0-9.
- Episode type - Defaults to None, select from the available list if required.
- Notes - Enter any free text as required.
Recording a Consultation (2.03)