In this article:
The Clinical tab of a patient's file is where all of their clinical information, including consult notes, are stored.
The Clinical tab is where you can manage the clinical aspects of the patient's health record.
On the right hand side of the Clinical tab you will see the Latest Measurements, Adverse Reactions, Medications, Diagnoses and Past Procedures tables where these details can be stored.
You can expand or hide each section to view its contents by clicking the drop down arrow just to the left of these headings.
Latest measures will display the most recent measurements added for the patient. This includes height, weight, BMI and BP for a patient.
For information, please see the Clinical Measures page.
Adverse Reactions can be used to record any allergies or reactions the patient is known to experience.
For information, please see the Adverse Reactions page.
The Medications table shows a list of all the patient's current, active medications and prescriptions.
You can quickly add a new medication to the table for record keeping purposes as follows:
- Click the + icon within the Medications table.
- The Add Medication section will open.
- Search for the medication.
- Select it from the results list.
- Press Save.
Please see the Prescribing article for detailed information on:
- adding medications for a patient
- creating and printing prescriptions
- inactivating/re-activating prescriptions
The Diagnoses module can be used to add details of a patient's current and past health conditions.
For information, please see the Diagnoses page.
The Past Procedures module can be used to add details of a patient's previous procedures, which may have been performed by other providers.
For information, please see the Past Procedures page.
You can use Consult Notes to record details of your contact with a patient.
For information, please see the Consult Notes page.
When writing Consult Notes, you can enter a reason for the patient's appointment or the presenting problem.
For more information, please see the Reasons for Encounter page.
Attachments can be used to add a variety of items to a patient's record, such as handwritten consult notes, images, and letters.
For more information, please see the Attachments page.
> Does dictation software work with Gentu?
Gentu does presently work with Dragon Medical Dictation, and we have a projected vision to have other VRS solutions implemented with Gentu in the future.
If you're interested in Dragon, we suggest you contact voicerecognition.com.au, the Australian resellers for Dragon software.
> Can I stop certain users from viewing clinical information?
Yes, the ability to view, edit and add clinical information can be managed from the User Roles within Settings > User Roles.
You can also lock clinical records - please see our Restrict Patient Records article for more information.