# Read and update a patient's record (/docs/en/learn/clinician-chart)



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 [#why]

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 A wrong entry is withdrawn, and it stays visible with the reason.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 [#how]

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 [#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 [#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](/docs/en/learn/clinician-record-and-sign).

### Correct a mistake [#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 &#x2A;*Withdraw…**. Salisan asks &#x2A;*Why is this withdrawn?**.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 A wrong value is corrected, not withdrawn. The withdrawn entry stays readable and struck through under **Withdrawn**, and **Undo withdrawal** brings it back.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 [#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](/docs/en/get-started/roles-and-access).

## Try it [#try-it]

You create the test patient that the later lessons reuse.

1. Open **Patients** and choose **New patient**.
2. 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 &#x2A;*Patient added.** appears.
3. Read the page. It says &#x2A;*Nothing in the record yet.** You are on the care team because you created the patient.
4. Choose **New**, then **Diagnosis**. Type a diagnosis name, for example Hypertension. If a list of catalog entries appears, pick the matching one. Choose **Record**.
5. Check that the diagnosis now appears under **Diagnoses**.
6. Click the diagnosis line. Choose &#x2A;*Withdraw…**, then **Test or accidental entry**, then **Withdraw**.
7. Look for &#x2A;*Withdrawn (1)** in the section and open it. The entry is struck through. Open **History** to see both steps.

<Callout type="info">
  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.
</Callout>

## Check yourself [#check]

1. The allergies line says **Allergies not recorded**. Does the patient have no allergies?

<details>
  <summary>
    Answer
  </summary>

  No. It means nobody has recorded anything yet. **No known allergies** is a separate statement that someone recorded.
</details>

2. You recorded a diagnosis on the wrong patient. Can you delete it?

<details>
  <summary>
    Answer
  </summary>

  No. Open it, choose &#x2A;*Withdraw…** with the reason **Wrong patient**, then record the diagnosis on the right patient. The withdrawn entry stays in the history.
</details>

3. A colleague can open a patient that is missing from your list. What is the most likely reason?

<details>
  <summary>
    Answer
  </summary>

  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.
</details>

## Next [#next]

Continue with [Start a visit and write the note](/docs/en/learn/clinician-visit).
