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 Structured Data Areas.

• Date, Clinician, In Practice or Private - see Date, Clinician, In Practice/Private
• Add your own free text Notes to a data entry screen. Some screens, for example, History-Add, may also have a Comments window where you can add free text.
• Recalls - how to enter recallsis explained in the section Recalls.
• Health Promotion is explained in the section on Health Promotion.
• Items of service claim - No longer relevant as Items of Service claims ceased in April 2004.
• Generate a referral letter, i.e. add correspondence (recall or referral)