Saving Clinical Responses to the Record
Clinical questionnaires generate proposed record entries from patient responses. A clinician reviews these proposals and selects which ones to save to the patient's clinical record.
What Are Proposed Record Entries?
When a patient completes a clinical questionnaire, the system maps their answers to SNOMED-coded clinical data. These are grouped by destination:
- Observations - vital signs and measurements (e.g. PHQ-9 score, BMI)
- Care History - social and medical history entries
- Clinical Findings - symptoms and clinical observations
- Flags - clinical alerts and warnings
- Emergency Contact - patient contact details
- Interpreter Needs - language and accessibility preferences
- GP Registration - registered GP surgery
Proposed entries are not saved automatically - they require clinician review.
How to Review and Save
- Open the questionnaire response from the patient's Questionnaires tab or the global responses list
- Click the Review button on the clinical response summary
- The review panel opens, showing:
- The patient's answers (question and answer view)
- Proposed record entries grouped by destination
- For admin fields (emergency contact, GP), a diff showing the previous value crossed out
- Select entries to save using the checkboxes (or use Select All)
- Click Save to Record (N) where N is the number of selected entries
Red Flag Alerts
If any questionnaire answers trigger a red flag (e.g. high-risk screening scores), a red banner appears at the top of the review panel. Review these carefully before proceeding.
Tracking Save Status
In the patient's Questionnaires tab, the Saved to Record column shows:
- Saved (green) - entries have been saved, with a count of how many
- Pending (amber) - this is a clinical questionnaire that has not yet been reviewed
- N/A - this is an administrative questionnaire with no clinical data
Important: Only save entries you have clinically reviewed. The system proposes entries based on the patient's answers, but clinical judgement should always guide what is recorded.