Clinical records
Add diagnoses, medications, allergies and readings, update their status, and withdraw an entry recorded in error.
The record is the structured part of a patient's chart: diagnoses, medications, allergies, readings and scheduled orders. You need write access to this patient's clinical records (Write assigned clinical records or Write all clinical records) to change it.
Add an entry to the record
- Open the right patient and look at the chart first, so you do not add a duplicate.
- Choose New, then an entry under In the record: Diagnosis, Medication, Allergy or Reading. The empty rows in each chart section do the same.
- Fill in the fields. Check the catalog item you picked, its status, any dates, and the dose or units.
- Choose Record, or Save in a dialog. Confirm that the entry now appears in its section of the chart.
You can also add entries while writing a visit. Those start as drafts and reach the record only when you record them; see Visits and notes.
The top of the chart shows allergies. Allergies not recorded means nobody has said anything yet. No known allergies is a statement someone recorded.
A medication entry documents a medication order in the record. It does not send a prescription anywhere. Search results depend on the catalogs your practice has switched on, so check the selected concept and units rather than the name alone.
Update an entry
Select a line in the chart to open it. Select a value to change it. Each change applies on its own, with no Save button. If the change is refused, the value goes back and the reason appears beside it.
A coded diagnosis or substance cannot be renamed into another concept. History on the sheet shows earlier changes.
The sheet offers the status moves that fit the entry:
- Diagnosis: Confirm while it is provisional or differential, or Mark resolved with an optional outcome.
- Medication, check-in or referral: Pause and Stop while active; Resume or Stop when paused; Restart once stopped or completed. Stop asks for a reason such as Course completed or Side effects.
Confirm, Resume and Restart apply at once. Mark resolved, Pause and Stop state their consequence first and apply when you confirm. For example, pausing also pauses patient emails for that item, and stopping a home-monitoring check-in cancels its future patient tasks. Answers already received stay in the record.
Withdraw an entry recorded in error
Clinical entries cannot be deleted. If an entry should never have been recorded, withdraw it. It stays readable and struck through, with the reason, who withdrew it and when. Withdrawn entries sit in a Withdrawn fold.
Decide first whether the entry was correct when you recorded it.
| Situation | Action |
|---|---|
| A course ended or a problem got better | Stop or Mark resolved. This is a clinical change, not an error. |
| A value was typed wrongly | Correct the value. The old value stays in History. |
| It was proven untrue (diagnosis or allergy) | Withdraw…, reason Turned out to be untrue, then Mark refuted. It moves to the closed entries. |
| Wrong patient, duplicate, test entry | Withdraw… with that reason, then record the right entry where it belongs. |
- Open the entry and choose Withdraw….
- Choose a reason. Other needs a note; the note is optional for the rest.
- Choose Withdraw.
Withdrawing changes the record other staff rely on, and the entry no longer counts as current. Choose Undo withdrawal on the entry if you withdrew the wrong one. If the patient's record is under a legal hold or restricted, withdrawal is refused until the compliance owner releases it.
Remove from note only takes an entry's reference out of a note. It does not withdraw the entry. Entries inside a signed note are read-only there; withdraw or correct them in the chart.
Correct a reading
Open Vitals to see readings with dates and trends. Select Edit on a reading, change the time or value, and choose Correct. The row then reads "corrected from" the earlier value. Check the unit and the measurement time before you compare readings. A reading entered by mistake is withdrawn like any other entry.