Adding Clinical Data

To add any type of clinical data to a patient record in Vision Anywhere:

Important - A patient record is not locked when you open an Encounter, other users can access and add to the same patient record at the same time.
Note - Vision Anywhere uses SNOMED CT to record data, please see SNOMED FAQ for further information.
  1. From Vision Anywhere, select the patient required, see Selecting a Patient in Vision Anywhere for details if required and create an Encounter, see Creating an Encounter for details if required:

  2. Enter a keyword in the dynamic search bar:

    The keyword can be to:

    • Record a medication, immunisation or clinical term.
    • Trigger a template or calculator.

    A single letter triggers a common observation quick entry, three letters or more returns a pick list of clinical terms

    There are some short cuts, for example, to quickly record a blood pressure, enter a reading for example 120/80 and select Blood pressure reading.

  3. Select the term required from the list and the relevant data entry form displays, or select SNOMED CT Browser to search further, see Using the SNOMED CT Browser if required.
    Note - SNOMED CT Preferred Terms are indicated with a PT indicator .
  4. Complete the form as appropriate, for example:

      • Description - Defaults to the term selected. You can change by searching an alternative term if required.
      • Priority - Defaults to 3, but you can select from 0-9.
      • Episode type - Defaults to None, select from the available list if appropriate.
      • Notes - Enter any free text as required.
  5. Select Save .

Recording a Consultation (2.03)

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