Adding Clinical Data

To add any type of clinical date 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, for further information please see SNOMED FAQ.
  1. From Vision Anywhere, select the patient required.
  2. Select New Encounter .

  3. Enter a keyword in the dynamic search bar:

    The keyword can be to:

    • Record a drug, 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 120/80 and select blood pressure reading.

  4. Select the term required from the list and the relevant data entry form displays.
    Note - SNOMED CT Preferred Terms are highlighted with a PT indicator .
    Note - England Only - QOF compliant terms are highlighted with a QOF indicator.
  5. Complete the form as appropriate:

      • 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 required.
      • Notes - Enter any free text as required.
  6. Select Save .
Note - You can also search the record during an Encounter. See Searching the Patient's Record.
See Using the SNOMED CT Browser, Selecting a Patient , Adding an Encounter , Templates and Calculators, Common Observations and Quick Entry Forms for further details.

 

Recording a Consultation (2.03)

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