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What are Summary Forms?

An alternative to using Management Plan guidelines is to enter data on a tabbed Summary Form. The field prompts are often identical on a Management Plan and its corresponding Summary Form – it is just a different way of entering the data.

As with a Management Plan, the relevant entries for a clinical category are grouped together on a single form or tabbed form. For example, the Lifestyle form includes entries for Occupation,Smoking, Alcohol, Exercise, Diet and Contraception. Other multiple tabbed forms include Asthma Management, Child Development, CV & BP Management, Haematology.

Each Tabbed Form is made up of several Summary Forms, for example, Maternity Care has tabbed sections for a Pregnancy Start, Ante-natal, Investigations, Outcome, Infant Details and Postnatal.

Any data entered in one field, such as Blood Pressure, will be repeated on any other form which has the same field, eg where there is a Blood Pressure prompt.

There are thus several places where you may enter a specific record. For example, you can record a urinalysis result for an ante-natal patient from either theMaternity Care tabbed form under Investigations; or from the Investigations part of Diabetes Management. You will then find that the same urinalysis result will be displayed on other forms with Urinalysis, such as the Female Health Check.

The system always tries to place your entry in the correct structured data area. If you are unsure what form to use, or where to find the entry on a form, then make a simple READ Term entry from the Patient Record – Record, or from Add – Select READ term, or from History – Add.