Read and update a patient's record

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 A wrong entry is withdrawn, and it stays visible with the reason.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 record header stays at the top of every tab of the record: the patient's name, key facts and the allergies line. 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.

The Record page starts with Needs you when something waits for you, then the lines Next visit and Care team. Below them come Diagnoses, Medications and Vitals, which are always shown. Sections such as With the patient, Tasks, Care plans and Home monitoring appear when they hold something. A section's title opens the full list. Anna has one confirmed diagnosis, one medication and three blood pressure readings from last month.

The other tabs of the record are Notes & files, Emails & requests, Tasks, Profile and History.

Add an entry

Choose Add in a section header, for example under Diagnoses or Medications. Under Vitals, the button reads Add reading. Allergies are added from the allergies line in the header. The entry opens in place. Fill it in and choose Record, or press Enter. The entry is in the record at once.

Inside a visit note it works differently: an entry joins the record when you sign the note. You meet that in Record findings and sign a note.

Correct a mistake

Select a line to open it, then change the value there. 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 Salisan asks Why is this withdrawn?.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 A wrong value is corrected, not withdrawn: if you choose Wrong value, Salisan offers Correct it instead →.

The withdrawn entry leaves the Record page. To find it, choose the section title, for example Diagnoses, and then the Withdrawn filter. The entry is struck through there, with the reason, and Undo 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.

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 Add patient. Patient added. appears and Sam's Profile opens.
3. Open the Record tab and read the page. Diagnoses and Medications say Nothing recorded yet. You are on the care team because you created the patient.
4. Under Diagnoses, choose Add. Type a diagnosis name, for example Hypertension. If catalog entries appear, pick the matching one. Choose Record. The diagnosis now appears under Diagnoses.
5. Select the diagnosis line. Choose Withdraw…, then Test or accidental entry, then Withdraw. The line leaves the Record page.
6. Choose the Diagnoses title, then the Withdrawn filter. The entry is struck through.
7. Open the History tab. Both steps are listed.

Check yourself

1. 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.

2. 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.

3. 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.