Patient records

Each patient's file (blood group, allergies, long-term conditions and medicines) and every visit: the complaint, vital signs, examination, ICD-10 diagnoses, the plan and the follow-up date. A signed visit can no longer change; later findings go in an addendum. Only clinical staff can open them, and every look or change is in the patient's access log. Part of the Patient records add-on for medical and acupuncture clinics.

Steps

  1. Give the doctors and nurses a role with Can open patient records switched on (Users → RBAC). Admin has it; no other role does until you switch it on.
  2. Open the patient under Customers and press Patient file. Fill in the blood group, allergies, long-term conditions and medicines and press Save file.
  3. Press New visit (or Customers → Patient records → New visit). Type the complaint and vital signs, search the diagnosis by name or ICD-10 code, write the plan and the follow-up date and save. The visit stays a draft until you sign it.
  4. Open the visit and press Sign visit when it is complete. A signed visit cannot be edited or deleted; when a result comes back, add it under Addenda.

Tips

  • Signing needs at least one diagnosis. The first diagnosis is the main one unless you tick another.
  • The access log on the patient file lists who opened or changed the file and its visits, and when. It names the fields that changed, never what was written in them.
  • Patient records are kept out of the AI assistant and the automations.

In the app, press F1 or ? on this screen to open this guide next to your work.

This guide belongs to the Patient records module. Learn more

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