How to Document Clinical Findings

The Clinical Record step is where you document your clinical findings. Jump uses a structured format based on the Problem-Oriented Medical Record (POMR) model — each problem has its own tab with dedicated sections for clinical notes.

The Clinical Record Editor

Clinical editor

After selecting problems (see How to Add Problems and Diagnoses), each problem appears as a tab at the top of the editor. Click a tab to switch between problems.

Each problem tab contains two groups of tools:

Record Section

Use these buttons to add clinical documentation:

History — patient-reported symptoms, timeline, and chief complaint
Examination — clinical observations, measurements, and vital signs
Family History — relevant family medical history and genetic factors
Social — social circumstances, lifestyle, and environmental factors
Comment — clinical reasoning, assessment notes, and treatment rationale
Procedures — clinical procedures performed or planned
Allergy — known allergies, adverse reactions, and sensitivities
Document — linked documents, correspondence, and reports

Click any button to expand its section. Type your notes in the text area that appears.

Action Section

Use these buttons to link structured clinical data to the consultation:

Medication — link or add medications
Immunisation — record immunisations administered
Referral — create a referral to another service
Investigation — order lab tests or investigations
Prescribe — create a prescription
Invoice — link a billing invoice

Each action opens a dialog or popover to capture structured data that gets linked to the consultation record.

Documenting Across Multiple Problems

If you're addressing more than one problem in a single consultation, use the problem tabs to document findings separately for each problem. This keeps your clinical record organised — when viewing the consultation later, notes appear grouped under the relevant problem.

Tip: Observations such as vitals (blood pressure, temperature, etc.) can be linked at the problem level. This means you can record which specific clinical problem prompted the measurement.

Auto-Save

Your work is saved automatically as you type. You'll see the draft status and last save time in the footer of the consultation wizard. If you need to step away, your draft will be waiting for you when you return — see How to Resume a Draft Consultation.

Next Steps

When you've finished documenting, click Review to preview your consultation before finalising it. See How to Review and Finalise a Consultation.