Recording Vitals & Notes
Recording patient vitals, consultation notes, follow-up tracking, document attachments, and clinical audit trails.
Recording Vitals & Notes
During a patient visit, staff and doctors record vitals and consultation notes. These form part of the patient's clinical record and are linked to the visit and appointment.
Vitals
Vitals are recorded at check-in or before the consultation begins. Common vitals include blood pressure, temperature, pulse rate, weight, height, and SpO2. The exact fields are configurable per hospital.
Vitals Workflow
- Patient checks in → visit is created
- Nurse or staff records vitals (linked to the visit)
- Vitals are available to the doctor during consultation
- If vitals are incorrect, they can be invalidated and re-recorded
Vitals Validation
Recorded vitals can be marked as valid or invalid:
- Valid — Values are correct and can be used for clinical decisions
- Invalid — Values were recorded incorrectly (wrong patient, equipment error, etc.). Invalid vitals are kept for audit but not shown as current readings.
The system tracks who recorded the vitals and when, creating an audit trail.
Consultation Notes
During the consultation, the doctor records structured clinical notes:
Field | What It Captures |
|---|---|
Chief Complaint | The primary reason the patient is visiting (in their words) |
History of Present Illness | Details of the current illness — onset, duration, progression |
Examination Findings | Physical examination results |
Diagnosis | Structured diagnosis (can be multiple diagnoses) |
Advice | Doctor's recommendations and instructions to the patient |
Follow-Up
If the doctor marks follow-up required, the system records how many days until the follow-up should occur. This can be used to suggest a follow-up appointment booking.
Doctor Signature
Consultation notes can require a doctor's signature before being finalised. The system tracks whether the notes are signed and when.
Documents & Attachments
Clinical documents (lab reports, imaging, referral letters) can be attached to a visit. Each document tracks:
Field | Purpose |
|---|---|
Source | How the document arrived: Upload (manual), Generated (system PDF), or External (third-party) |
Category | Document type (tenant-configurable categories) |
Verification | Whether the document has been verified by a doctor, and by whom |
Expiry Date | Optional expiry for time-sensitive documents (e.g. insurance pre-auth) |
Tags | Searchable tags for easy retrieval |
What's Next?
Learn about writing prescriptions in Prescriptions.
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