Using the Consultation View Menu and Data Entry

  1. Select a patient and make sure a consultation is open. The Patient Record should be displayed. If not, click on the Patient Record icon CM PRV View Record Icon or press F10, or select Consultation - View Patient Record.
  2. The Consultation View screen displays for Topic 1 (for further topics, see Topics).
    Note – You can start typing a READ term straightaway without even selecting an option as long as Enable Read popup dialog is checked in Consultation - Options - Setup - PatientRecord. Press Enter after typing in the keyword and the -Add screen will be displayed for the appropriate structured data area form.
  3. On the Vision 3 view, select Add from the main menu, then Category.
  4. Click on one of the menu options, or press Enter on a highlighted option (use the down/up scroll arrow to move the highlight).
  5. This will display an Add screen for the category. If a History Add screen, the Type of Characteristic will reflect what you choose in step 3 above, eg Presenting Complaint, Symptom, Examination, Diagnosis, Intervention.
  6. READ TermAdd – Select the READ term on this screen. Notice that Type of Characteristic will automatically default to the correct SEDI (symptom, examination, diagnosis or intervention), depending on the READ code used (for example, codes beginning with 1 are symptoms, those with 2 examinations and so on.
  7. For example, if the patient has a rash, type in rash in READ term for Characteristic, and press Enter. 1D14.00 C/O:a rash displays, with Type of Characteristic as symptom. If you use the scroll arrow to go to the next READ term, 2227.00 O/E - rash present , the Type of Characteristic changes to Examination. Continue scrolling down until you find the READ term you want.
  8. Optionally choose the Episode Type and Priority.
  9. Select OK.
  10. Many of these options are available from either the Add menu under Category, or from the Summary menu- Routine Checks or Disease Management.
    • Complaint - This displays a History-Add screen. The Type of Characteristic defaults to Presenting complaint.
    • Symptom - This displays a History-Add screen. The Type of Characteristic defaults to Symptom.
    • Examination - Click on Examination and select from:
    • Physiological measurements (including BP, weight etc)
    • Other Findings (History-Add) - Note the point about READ entries and SEDI above.
    • Test Results - Pathology (including Biochemistry, Haematology, Microbiology, Serology, Other Pathology); Imaging form (for X-rays, Contrast and Vascular studies, ultrasound etc), or the Other Tests form (ECG, Lung function, Endoscopy, Other)
    • Diagnosis - This displays a History-Add screen. The Type of Characteristic will automatically default to the correct SEDI depending on the entry, but initially is Diagnosis. For example, type in Asthma in READ Term for Characteristic and press Enter. This displays H33..00 Asthma. Scroll down one by one, and at each READ option, note how Type of Characteristic changes from Diagnosis to Symptom to Intervention, depending on the READ description displayed.
      Note - If the READ term you have entered has triggered a guideline, and the option to display guidelines after history entries is switched on, you will be asked if you want to view this. See Select Guideline for Patient in the Guidelines section.
    • Intervention - Click on Intervention for the following options:
    • Prescribe Acute (for the Acute Therapy List)
    • Prescribe Repeat (for the Repeat Therapy List)
    • Request Test
    • Pathology
    • Diagnostic Imaging
    • Other Tests
    • Refer (for Referral Add)
    • Procedure - a History-Add screen, with a Type of Characteristic of Intervention. This is particularly for practice nurses, or minor surgery procedures. You will see the Items of Service icon flashing if (1) a READ code from Chapter 7 for a minor surgery procedure has been entered, and (2) Intervention remains the Type of Characteristic, and (3) in Options Set-Up - General, you have switched on Display IOS Warnings for Medical History.
    • Immunise (for Immunisation Add)
    • Offer Advice (for the Advice Given - Add screen)
    • Management - Click on Management for the options:
    • Lifestyle - entries for Occupation, Smoking, Alcohol, Exercise, Diet, Contraception
    • Routine Checks - New Registration, Child Health, Maternity, Female Health Check, Male Health Check, Elderly
    • Disease Management - Asthma, Diabetes, CV/BP, Epilepsy
    • Administration - Click on Administration for the options: Recalls; Occupation; Correspondence
    • Another Topic - Click on Another Topic to start a second topic within the same consultation (see Topics). You have to have entered a first topic in the current open consultation to use Another Topic. (You can also reach Another Topic from the Consultation menu).
  11. Click on Close to exit. For more details about entering records, see Topics, and Problem Oriented Medical Records.

    The data entry screens you can select from the Options menu can also be accessed in other ways:

  12. From the Add Menu: Add-Category (Complaint, Symptom, Examination, Diagnosis, Intervention); Add-Recalls, Add-Correspondence, Add-Therapy, Add-Immunisations, Add-Test Results, Add-Referrals, Add-Requests, Add-Advice,
  13. From the Summary Menu: Summary-Routine Checks, Summary-Disease Management, Summary Physiological Measurements
  14. From the Consultation Menu: Consultation-Another Topic.
Note – To print this topic select Print in the top right corner and follow the on-screen prompts.