Adding Clinical Data

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

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, 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.
   Note - SNOMED CT Preferred Tered 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 .