Clinical Record

Viewing and managing the patient clinical record

22 articles

Failed-booking alerts and questionnaire red-flag escalationWhy "Failed booking" alerts and automatic red-flag urgency on episodes appear in your practice.Family and social history on the patient recordWhere to find and how to record family history and social history on the patient record.Locking the prescriber to the signed-in clinicianControl whether prescribing and reauthorising attribute to the signed-in clinician or allow free choice.Drug-Drug Interaction AlertsAutomatic safety alerts when prescribing medications with known interactions.Ordering Lab TestsVideoOrder pathology tests via TDL or Salient Bio, select tests from the catalogue, generate QR codes, and print request forms.Recording ObservationsVideoRecord vital signs and clinical measurements such as blood pressure, heart rate, temperature, weight, and height.Navigating the Patient RecordVideoUnderstand how the patient record is structured, including the main tabs, clinical record sidebar, and patient sidebar.Managing Problems and DiagnosesVideoAdd, edit, and track patient problems with SNOMED coding, significance levels, and status management.Managing MedicationsVideoView and manage a patient's acute and repeat medications, including adding, pausing, stopping, and reauthorising.Managing ReferralsVideoCreate and track referrals to other services with priority levels, status tracking, and linked documents.Managing Lab OrdersTrack lab order statuses, view order details, monitor result progress, and manage orders from the Lab Requests page.Creating a ReferralVideoCreate a referral to a specialist or service with SNOMED-coded specialties, contact selection, clinical reasons, and priority.Issuing a PrescriptionVideoCreate a prescription from issued medications, review patient details, select a prescriber and issue method, and send or save the prescription.Care History and EpisodesVideoView the chronological clinical timeline and manage episodes of care for patient pathways.Recording AllergiesVideoRecord drug and non-drug allergies with criticality levels, reactions, and NKDA status.Using the Patient SummaryVideoUse the Summary tab for quick actions, view draft consultations, recent activity, and open tasks at a glance.Prescribing Safety AlertsUnderstand clinical decision support alerts during medication issuance, including allergy warnings, interactions, and how to override when clinically appropriate.ScanCom Imaging ReferralsBook imaging referrals through ScanCom with modality selection, safety screening, and provider booking.Viewing Lab ResultsVideoView lab results in the patient record, understand abnormal flags and reference ranges, switch between rich and classic views, and view PDF reports.Filing Lab ResultsVideoMatch incoming lab results to patients, review abnormal values, add clinical codes, create follow-up tasks, and finalise filing.Reauthorising, Changing, and Stopping MedicationsVideoExtend repeat medications, change medication types, and stop medications with a documented clinical reason.Pathology ReportingUse the Pathology page to view lab requests, incoming results, and analytics on test volumes and turnaround times.

Medications

Locking the prescriber to the signed-in clinicianControl whether prescribing and reauthorising attribute to the signed-in clinician or allow free choice.Drug-Drug Interaction AlertsAutomatic safety alerts when prescribing medications with known interactions.Managing MedicationsVideoView and manage a patient's acute and repeat medications, including adding, pausing, stopping, and reauthorising.Issuing a PrescriptionVideoCreate a prescription from issued medications, review patient details, select a prescriber and issue method, and send or save the prescription.Prescribing Safety AlertsUnderstand clinical decision support alerts during medication issuance, including allergy warnings, interactions, and how to override when clinically appropriate.Reauthorising, Changing, and Stopping MedicationsVideoExtend repeat medications, change medication types, and stop medications with a documented clinical reason.

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