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Patient Medical Profile

Patient Medical Profile

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Crucial Information To Note:

Viewing Related Information

Information linked to a patient’s Consultation Notes will appear in the corresponding subsections here.
Any new details you enter directly in this section will also be displayed, even if they are not part of a Consultation Note.

Tracking Changes

All edits made within this area can be viewed under Change History, accessible via the button above the Patient History section on the left.

Please note:

Updates to Social History and Gynecology & Obstetrics are tracked separately within their respective sections under History.

 

Patient Info Card

Patient Information Overview

This section displays key details about the patient:

  1. Profile – Patient image (optional), name, age, and gender

  2. Contact & ID – Date of birth, registration number, country, and email

  3. Drug Allergy – Details and functionality explained [here]

  4. Billing – If you create a bill from this section, it will be outside of an appointment. Make sure you select the correct date and time from the Appointment dropdown as the last date will be preselected. Additional details and unctionality explained [here].

  5. Telemedicine – Details and functionality explained [here]

Vital Signs

This section displays the patient’s vital signs.

Please take a look at the Vital Signs sections at the top of this article here.

Consultation Notes

1. Consultation Notes

Selecting this tile opens the Consultation History pop-up, showing a list of all the patient’s consultation notes.

Key Columns

  • Diagnosis – Displays the diagnosis or diagnoses recorded for each consultation.

  • Notes – Indicates if information was entered in the Subjective, Objective, Assessment, or Plan sections.

  • Actions – Contains four icons:

    • Amended Notes – Create an amended note for a finalized consultation. If the note is locked but not discharged, go to Unfinished Notes to request an unlock instead of adding an amended note. Details and functionality are explained [here].

    • View – Opens the selected consultation note.

    • Referral Letter – Create a referral letter from this specific note.

    • Clinical Summary – Create a clinical summary from this specific note.

Refer to The Consultation Notes subcategory [here].

Labs and Imaging

Please take a look at the Labs and Imaging article here.

Documents

Documents have two subsections:

  • One for Documents uploaded
  • One for Lab and Imaging Results documents attached to Lab Orders

To Upload Documents

  1. Select the Type

  2. Choose the File from your device.

  3. Add Comments (optional)

  4. When finished, click Upload.

To Share Documents with Patients

  1. Go to the table with the saved documents.

  2. Select Add to Patient Portal

    • The button will change to Remove from Patient Portal if you need to revoke access.

  3. The patient will then see the document in the Documents section of their Patient Portal.

Misc. Notes

This is where you will document notes that wouldn't necessarily fall into the other categories. These include:
Electronic Communication, Phone Conversation, Document Reference, Other

To create a Misc Note:

  1. Select the Type
  2. Use Note text to enter the relevant information
  3. When finished, click Add.

Users can filter by Date, Type, and Users.

 

Patient History (Dx List)

  • The Dx List section has two subsections:
    • Diagnoses History, where you can enter any Diagnoses outside of an appointment, also diagnoses from the Subjective section of the Consultation Notes are saved here.
    • Diagnoses from Consultation Notes are saved from the Assessment Extras section on the Consultation Notes.

How to Add a Diagnosis 

  1. Make sure Diagnoses is selected from Diagnoses | Diagnoses from Consultations.
  2. elect the + Add Diagnosis Button.
  3. Search for the ICD-10 Diagnosis either by code or name.
    • Comments are optional.
  4. When finished, select Add.

 

Patient History (Allergy)

Adding Known Drug Allergies:

  1. Select + Add Allergy in the pop-up.
  2. Select the Allergy from the dropdown
    • See the Adding Allergies Not in the List below
  3. Add the allergy details (location, reaction, severity, and notes are optional).
  4. Click Add to save.

Adding Known Allergies (Contact Environment, Food):

  • Follow the same steps above

Marking No Known Allergies:

  • Select Drug, Contact, Food, or Environment in the No Known Allergies section for the types of allergies the patient does not have.

Adding Allergies Not in the List:

  1. In the Allergies dropdown list, there are five options:
    • Other
    • Other- Contact
    • Other- Drug
    • Other- Environmental
    • Other- Food
  2. Select the correct option (if you want the Drug Allergy Alert to show, choose Other: Drug Allergy), then enter the name of the allergy into the provided text box and save

Patient History (Medications)

The Medications section has three subsections

  • Prescriptions
  • Administered Medications
    • Medications Administered in your clinic
  • Past/Current Medications
    • Previous medications or current medications the patient is using.

How to Create a Prescription

  1. Make sure Prescriptions is selected from Prescriptions | Administered Medications | Past/Current Medications.
  2. Select the + Add Medications button.
  3. Select the Pharmacy for the prescription.
    • In-House- The prescription will be sent to your pharmacy within your clinic. 
      • Please note: Only medications that are priced will be in the dropdown for in-house prescriptions.
    • External - This creates the prescription for a third-party pharmacy, which you would need to print or send digitally using an agreed medium for that pharmacy.
  4. The Medication list lets you select the medication you are adding to the prescription.
    • If the medication is not there, type out the medication name, route, type (tablet, solution, etc.), and dosage. For example: Acarbose oral tablet 20 mg 
  5. Add Per Day, Duration, and Repeats.
  6. Add any Directions you want the patient and pharmacy to follow.
  7. If Substitutions are allowed, select the checkbox.
  8. To add another Medication, select Add medications.
  9. Select the Add button.

If patients usually have the same or similar prescriptions, you can recreate that entire prescription and make edits instead of creating that prescription from scratch

  1. Select the Copy prescription button
  2. Search for the prescription and select the Copy button for that prescription.
  3. Make any necessary edits, then select the Add button.

 

How to add Administered Medications

  1. Make sure Administered Medications is selected from Prescriptions | Administered Medications | Past/Current Medications.
  2. Select the + Add Medications button.
  3. Select the Administered Date and Time.
  4. Select the medication from the Medication list dropdown list then the Quantity.
    • If the medication is not there, type out the medication name, route, type (tablet, solution, etc.), and dosage. For example: Acarbose oral tablet 20 mg 
    • Select the Add medication button to add more medications
  5. Comments are optional.
  6. When finished, select Add.

How to add Past/Current Medications

  1. Make sure Past/Current Medications is selected from Prescriptions | Administered Medications | Past/Current Medications.
  2. Select the medication from the Medication to Note dropdown.
    • If the medication is not there, type out the medication name, route, type (tablet, solution, etc.), and dosage in the dropdown and then select it. For example: Acarbose oral tablet 20 mg 
  3. Select if it is a Past or current medication from the Past/Current Medication dropdown.
  4. Per day, Duration, and Comments are optional.
  5. When finished, select Add.

Patient History (Immunizations)

How to add an Immunization

  1. Select the +Add Immunization button.
  2. Select the Vaccination type, Dosage, and Administered Date.
  3. Body site, Route, Lot No, Expiry date and Comments are optional.
  4. When finished, select Add.

Patient History (Family History)

How to create Family History

  1. Select the +Add Family History Button
  2. Relationship is mandatory.
  3. First and Last name, Date of birth, and Date of death are optional.
  4. Select the Add diagnostic button and select the Diagnosis the relative was diagnosed with.
    • Age of Onset is optional
    • To add another diagnosis, select the Add diagnostic button
  5. Comments are optional
  6. When finished, select Add.

Patient History (Social History)

  • Social History has some present questions that your clinic admin can make active or inactive.
  • Administrators can create new questions.

How to make questions Active and Inactive and 

  1. Navigate to the My Profile drop-down and select Clinic Settings.
  2.  Here, you can select which question to have active.

Create New Questions for Social History

  1. Navigate to the My Profile drop-down and select Clinic Settings.
  2. In the Custom Questions section, enter the question in the Question text field and select the +Add new question button.

Patient History (Past Medical History)

Enter Blood Type 

  1. The Blood Type section is to the top right
  2. Select the edit icon and enter the blood type

How to Add Medical History

  1. Select the + Add Medical History Button
  2. Select the Medical condition from the dropdown
    • If the medical condition is not there, search and select Other
    • or type out the name of the medical condition in the dropdown and then select it
    • Enter the name of the medical condition in the Comments section
  3. Use the Comments to enter any information
  4. When finished, select Add

Patient History (Surgical History)

How to enter Surgical History

  1. Select the +Add Surgical History button.
  2. Select the surgery from the Surgery list dropdown and add the Date.
  3. Comments (Note text) are optional.
  4. When finished, select Add

Patient History (Procedure)

How to enter Procedures

  1. Select the +Add Procedure button.
  2. Select the procedure from the Procedure dropdown and add the Date.
    • If the procedure is not there, search and select Other
    • or type out the name of the procedure in the dropdown and then select it
  3. Comments (Note text) are optional.
  4. When finished, select Add

Patient History (Gynaecology and Obstetrics)

Gynaecology and Obstetrics have two sections

  • Gynaecology
    • This has various text fields and check boxes.
  • Pregnancy History
    • This has various text fields to be filled.
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Tags: lab, imaging, consultation note, vital signs, documents, patient history, misc, change history, patient information
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