Elements of a patient's health record

Elements and format of a patient's health record

Patients' health records include case notes, appointments, referrals, reports, assessments, social history, general notes and any other records associated with a patient's health. From a patient's Clinical tab, you can enter and format case notes, reports and assessments, create your own templates or import them from the HealthKit template library, and save and publish (i.e. lock down) health records. You can also update fees for the appointment.

The elements of a patient's health records are shown below.

Health records listing

The health records listing down the left hand side of the Clinical tab lists all elements of a patient's health record, including:

  • Appointment case notes
  • Referrals, under which associated referral acceptance letters, clinical reports and saved files are shown
  • Clinical reports, assessments and saved files
  • General and other notes

Each record is shown in blue, with the record that you are currently viewing shown in green. Files are shown in grey.

Save, publish and delete patient records

Main articles: Saving and publishing patient records and Deleting patient records

All patient records are automatically saved as you type. You can change the status of records from Draft to Published (i.e. locked down) by clicking the small arrow to the right of the save button. This is also where you can delete certain patient records.

Appointment details

The appointment details section takes information from your calendar, and lists the appointment date and time, the name of the practitioner and the practice location at which the appointment occurs.

Updating fees and invoices from patient records

Main articles: Updating fees and invoices from patient records

You can edit and add fees to an invoice while you are entering and reviewing patient records by clicking the arrow next to the invoice number in the appointment details section of the patient record, and making the required changes.

Add file

Main article: Adding files and images

You can add files including referrals, photos, handwritten notes, etc by clicking the Add File button.

Formatting patient records

Formatting patient records

Main article: Formatting patient records

Once you have created the required patient record (or once it has automatically been created for you), you can begin entering patient records, including case notes, letters, referrals, reports and assessments. Formatting your records is similar to formatting in Microsoft Word, and you can format text and paragraphs, move text, add tables and lines. You can also add images and dynamic terms, as well as select your preferred template. You can also change the size of your screen to maximise the editing space available.

Case note/report

This is the area in which you record your case note or clinical report.