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, for further information please see SNOMED FAQs.
  1. From Vision Anywhere, select the patient required and view their Patient Summary.
  2. Select New Encounter and the Current Encounter screen displays:

  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, see Templates and Calculators for details if required.

    A single letter triggers a common observation quick entry, three letters or more returns a list of clinical terms to select from.

    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.
    Training Tip - 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, see What is a Priority? for details if required.
      • 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 for details.
See Using the SNOMED CT Browser, Selecting a Patient , Adding an Encounter, Templates and Calculators, Quick Entry Forms for further details.

Recording a Consultation (2.03)

Note – To print this topic select Print in the top right corner and follow the on-screen prompts.