A finding I wrote is not in the record
Find out why a diagnosis, medication, allergy or reading from a note is missing from the patient's record.
ForDoctorsNurses
You added a finding in a visit note, but it is not on the patient's Record page. A note and the record are separate. A finding block in a note is a draft until you add it to the record.
Check these first
- Check whether it is still a draft. Open the note. The top of the note offers Add 3 to the record, where the number is how many drafts are ready. A visit left unsigned for more than a day also shows a card on the patient's page with the number of drafts not in the record. Choose Record in the block, or Add N to the record for all of them. Signing also records every ready draft.
- Look for a block that failed. A block that could not be recorded shows an error and Try again, and a message tells you how many drafts failed. The others are already recorded, and trying again does not record them twice.
- Check that the block is complete. The count at the top only includes drafts that can be recorded. A block with a missing name or value is not counted. Complete it or choose Remove.
- Remember that keeping Agent text is not recording. Findings the Agent suggested stay drafts until you record them. See Visits and notes.
- Look in the right place. The Record page shows current entries under Diagnoses, Medications, Vitals, Home monitoring and Forms. A resolved diagnosis or a stopped medication moves into Closed (n) at the end of its section. An entry recorded by mistake is under Withdrawn (n). A section with nothing in it is hidden, and the line Not in the record yet names what is missing.
- Check the patient. Confirm that the name and date of birth at the top belong to the patient you meant.
Do not type a recorded finding again. A second entry creates a duplicate.
If it still doesn't work
Leave the note as it is and choose Help & support from that page. See Contact support.
Send the time, the kind of block (for example diagnosis, medication or reading), what the block shows and the message, if any. Do not send the patient's name or the finding itself.
See also Clinical records for entries recorded in error.