Vitals and clinical notes

Rules for recording vitals and consultation notes - open visits, required values, BMI, diagnosis types, follow-up, and where the records appear.

Vitals and consultation notes are the core of every visit's clinical record. Both are entered through forms: vitals on the Record Vitals tab, notes on the doctor's Consultation Notes tab. This page explains the rules LeapHealthOS applies when they are saved, which fields exist, and where you can see them afterwards. It is for nurses, doctors, counsellors and administrators.

For the screens themselves, see Care Station and the Units board and Consultations.

Vitals

Where vitals are recorded

Workspace	Tab	Who
Care Station	Record Vitals	Nurses
Consultations	Record Vitals	Doctors
Counselling	Record Vitals	Counsellors

All three use the hospital's published Nurse's page form, so the questions are the same everywhere.

Rules when vitals are saved

The visit must be open. Vitals can only be recorded while the patient's visit is checked in or in progress. Otherwise you see Visit is not in an open state.
At least one value is needed. A form with no readings is refused with At least one vitals field must be provided.
The visit moves to in progress. Recording vitals on a checked-in visit marks the visit as in progress.
BMI is calculated for you. When weight (kg) and height (cm) are both present, BMI is worked out and stored to one decimal place.
Each submit is a new record. Submitting the vitals form again adds another vitals record for the visit; it does not overwrite the first one.
Vitals status. On the Care Station queue, an appointment shows Completed once a valid vitals record exists for it, and Pending until then.

Vitals fields

Your form decides which of these are asked. Medical History shows them with these labels and units.

Field	Unit
Systolic BP	mmHg
Diastolic BP	mmHg
Pulse Rate	bpm
Temperature	°C or °F
SpO₂	%
Respiratory Rate	/min
Height	cm
Weight	kg
Blood Sugar	mg/dL
BMI	calculated
Notes	free text

Blood pressure, pulse and temperature unit

With some vitals forms, blood pressure and pulse appear in Medical History without their units, and a temperature recorded without a unit is shown in °F, even if it was measured in °C. Your administrator should check this before go-live; see Clinical forms and placements. If a reading looks wrong in Medical History, tell your administrator rather than re-recording it.

Valid and invalid vitals

Every vitals record is either valid or invalid. Invalid records (for example readings taken on the wrong patient or with faulty equipment) stay in the patient's record but are left out of Medical History and the vitals status. Every record keeps who recorded it and when.

No screen to correct or invalidate vitals

LeapHealthOS has no button to edit a vitals record or mark it invalid. If a reading was recorded incorrectly, record a new, correct reading and add a note explaining the correction in your form's notes field, then ask your implementation team to mark the wrong record invalid.

Consultation notes

A consultation note belongs to a visit and its appointment. It is saved when the doctor submits a consultation form that has a notes section.

Note fields

Field	What it captures
Chief complaint	The main reason for the visit, in the patient's words
History of present illness	Onset, duration and progression of the current problem
Examination findings	Results of the physical examination
Diagnosis	One row per diagnosis, with a diagnosis type and a description
Advice	Recommendations and instructions to the patient
Follow-up required	Whether the patient should come back
Follow-up in (days)	How many days until the follow-up. If your form asks for a date instead, it is converted into the number of days from today.

Rules when a note is saved

The visit must be open. Notes can only be saved while the visit is checked in or in progress. Saving the first note on a checked-in visit marks the visit as in progress.
The author is the appointment's doctor. The note is recorded against the doctor on the appointment, not against whoever is logged in. If the appointment has no doctor, the note is refused.
Diagnosis types are checked. If your hospital has set up Diagnosis Types in SettingsPlatform ConfigurationTenant Registry, each diagnosis row's type must be one of the active types. Otherwise the submit fails with Invalid or inactive diagnosis type. See Tenant registry and vocabularies.
Each submit is a new note. Submitting the consultation form again creates another note; it does not edit the first one.

Follow-up

When a note says a follow-up is required, the task details for that appointment offer a Book follow-up action (with in N days when a number of days was given). It opens the booking wizard with the patient and doctor filled in. See Working a task.

Viewing and signing notes

Saved consultation notes are not displayed on any screen in LeapHealthOS yet, and notes cannot be signed from the app. Until this is available, keep information the next clinician must see in the prescription's diagnosis summary and advice, which are printed on the prescription PDF.

Where clinical records appear

Place	What you see
Medical History tab	Valid vitals snapshots, reports and active documents in one searchable list, each with an IVY summary
Case Record tab	Each appointment, with View Vitals, View Reports and View Prescription on completed ones
Logs tab	A day-by-day timeline: Vitals, Test Ordered, Report Verified, Report Delivered, Prescription Issued and more, each with a button to view details
Care Station queue	The appointment's vitals status

Documents, consent forms and the document checklist are covered in Document checklist and consents.

vitalsnotesdiagnosisfollow-upbmiclinical records