General Screen Entries
This section describes the field prompts common on most data entry screens:
- Read Term - Add - This data entry window is present on many of the Patient Record views. Either enter a keyword, for example, cardiac, or a code preceded by #, for example, #G57 cardiac dysrhythmias. When you click OK, the data may be placed in a structured data area (SDA) if there is one (for example, Asthma-Add), and if not, in generalised medical history.
- ReadTerm for Characteristic - Many specific screens already have a default Read term selected; and on some, if you click on the selection arrow in this window, you can reveal a picklist of relevant Read terms from which you can choose.
The Read Term for Characteristic is blank on History-Add screen. Either type in a Read keyword and press Enter, or type in # followed by a Read code. For how to select a Read term, see Add a medical history and Quick add of Read descriptions from front - Add screen. Medical History entries are not placed in stuctured data areas, see Structured Data Areas for details.
- Date, Clinician, In Practice or Private - See Date, Clinician, In Practice/Private for details.
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Notes - Add your own free text to a data entry screen. Some screens, for example, History - Add, may also have a Comments option where you can add free text, see Notes for details.
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Recalls - how to enter recalls is explained in the section Recalls.
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Health Promotion is explained in the section on Health Promotion.
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Items of service claim - No longer relevant as Items of Service claims ceased in April 2004.
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Generate a letter, for example, add correspondence (recall or referral)
Note - To print this topic select Print
in the top right corner and follow the on-screen prompts.
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