Read and update a patient's record
Open a patient's record, read its sections, add a diagnosis and withdraw an entry you recorded by mistake.
After this lesson you can read a patient's Record page, add a diagnosis to it and correct a mistake. It takes about 15 minutes. You need a role that can write clinical records, such as Member, Admin or Owner.
Why it matters
The Record page is the summary every colleague reads: allergies, diagnoses, medication, readings and open work. What is recorded there counts as current for the whole practice. So you read it before a contact, and you add to it on purpose.
Nothing recorded is ever deleted. A wrong entry is withdrawn, and it stays visible with the reason.
How it works
Anna de Vries, 54, comes for a follow-up. Her doctor opens Patients, searches for her and checks her name and birth date before opening the row. A matching name alone is not enough.
What the Record page shows
The top of the page holds the allergies line, the care team, the next appointment and the last visit. Allergies not recorded means nobody has said anything yet. No known allergies is a statement someone recorded. Anna's allergy to penicillin is listed there.
Below that come the sections Diagnoses, Medications, Vitals, Home monitoring, Forms, Care plans, Tasks and Activity. Anna has one confirmed diagnosis, one medication and three blood pressure readings from last month.
The other pages of the record are Visits, Documents & files, Tasks, Care plans, Emails, Requests and History.
Add an entry
Choose New, then an entry under In the record: Diagnosis, Medication, Allergy or Reading. The block opens on the page. Fill it in and choose Record, or press Enter. The entry is written to the record at once.
Inside a visit note it works differently. Entries there start as drafts. You meet that in Record findings and sign a note.
Correct a mistake
Click a line to open it. Click a value to change it. Each change applies on its own. A diagnosis can also be confirmed or marked resolved when that is the clinical change.
If an entry should never have been recorded, choose Withdraw…. Salisan asks Why is this withdrawn?. The reasons include Wrong patient, Duplicate and Test or accidental entry. A wrong value is corrected, not withdrawn. The withdrawn entry stays readable and struck through under Withdrawn, and Undo withdrawal brings it back.
Which patients you see
With the default Member role you see the patients assigned to you. A patient you register is assigned to you. If a colleague can open a record that you cannot, ask a practice admin to check the assignment. See Roles and access.
Try it
You create the test patient that the later lessons reuse.
- Open Patients and choose New patient.
- Enter Sam as Given name, Testpatient as Family name, and a Birth date that makes Sam an adult. Choose Create patient. The record opens and Patient added. appears.
- Read the page. It says Nothing in the record yet. You are on the care team because you created the patient.
- Choose New, then Diagnosis. Type a diagnosis name, for example Hypertension. If a list of catalog entries appears, pick the matching one. Choose Record.
- Check that the diagnosis now appears under Diagnoses.
- Click the diagnosis line. Choose Withdraw…, then Test or accidental entry, then Withdraw.
- Look for Withdrawn (1) in the section and open it. The entry is struck through. Open History to see both steps.
You cannot delete Sam. Keep "Testpatient" in the name. Open Patient actions → Edit, choose More details and turn on Exclude from analytics, so Sam does not count in Insights. Withdraw test entries with Test or accidental entry. Permanent removal is a formal erasure that only an owner or admin can start.
Check yourself
- The allergies line says Allergies not recorded. Does the patient have no allergies?
Answer
No. It means nobody has recorded anything yet. No known allergies is a separate statement that someone recorded.
- You recorded a diagnosis on the wrong patient. Can you delete it?
Answer
No. Open it, choose Withdraw… with the reason Wrong patient, then record the diagnosis on the right patient. The withdrawn entry stays in the history.
- A colleague can open a patient that is missing from your list. What is the most likely reason?
Answer
Your role gives you access to assigned patients only, and this patient is not assigned to you. Ask a practice admin to check the assignment.
Next
Continue with Start a visit and write the note.