Clinical - Admission History

Managing a patient’s Admission History in MediRecords helps you keep track of hospital visits, procedures, and treatment details all in one place. By recording and updating admissions directly in the patient’s clinical record, you create a reliable history that supports better decision-making and continuity of care across your practice. Each record captures key information such as admission dates, facilities, length of stay, reasons for admission, and related procedures.

This article will show you how to view, filter, and search admission records, as well as how to create new entries and update existing ones. You will also learn how to make records confidential, link them to Today’s Notes, and generate printed reports when needed. With these tools, MediRecords makes it easy to maintain accurate admission histories that improve patient outcomes and provide clinicians with the context they need at a glance.
Contents

1. Key Differences Between Admissions Module and Admission History (Clinical Record)
2. Viewing and Customising Admission History (Admission Tab)
3. Viewing the Admission History (Clinical Tab)
4. Filtering Admission History
5. Searching within the Admission History
6. Adding a New Admission History Record
7. Inserting an Admission History in Today's Notes
8. Making an Admission History Record Confidential
9. Editing an Admission history
10. Printing an Admission History Record
11. Deleting an Admission History Record

Key Differences Between Admissions Module and Admission History (Clinical Record)

While both the Admission History in the Clinical Record and the Admissions Module relate to hospital admissions, they serve different purposes and follow distinct workflows. Understanding these differences is essential for accurate documentation and appropriate use of each feature.

Purpose and Workflow

• Admissions Module:
  Designed to manage a patient’s active hospital journey. It includes clinical documentation, tracking of treatment progress, and discharge processes. The workflow is interactive and multi-step — from admission through to discharge — and includes features like letter generation and status updates.

• Admission History (Clinical Record):
  Intended for record-keeping of past or planned admissions. Entries are often added manually by clinicians to ensure historical completeness. There is no associated workflow; it's purely for documentation purposes through simple data entry.

In summary:

• Use the Admissions Module to manage current or formal admissions, including full clinical documentation and workflow support.

• Use the Admission History section to log past or upcoming admissions for informational or historical purposes only.

Recognising these differences ensures clean data entry, accurate patient records, and the appropriate use of each feature in MediRecords.

Viewing and Customising Admission History (Admission Tab)

The Admission History feature in MediRecords provides a detailed overview of a patient’s past admissions, making it easier for clinicians to review critical information at a glance. This includes admission details such as facility, attending consultant, reason for presentation, procedures performed, length of stay, and discharge summaries.

To support different workflows, the Admission History list can be customised by rearranging the displayed columns. This flexibility ensures that users can organise information in a way that best suits their clinical or administrative needs, improving both efficiency and visibility of patient admission records.

1. Click on Admissions, then click on the Patient Name
   
   
    
2. Click on Admission History
   
   
    
3. This will show the Date and Time, ID, Status, Facility, Attending Consultant, Attendance Type, Reason for Presentation, Procedure, Length of stay, Discharge Date and Discharge Summary.
   
   
    
4. You have the option to customise the columns base on how you want it to be presented by clicking on the three dots.
   
   
    
5. Just click and drag the items to you preferred arrangement then click Apply.
   
   
    
6. The desired preference has now been applied
   

Viewing the Admission History (Clinical Tab)

The Admissions page in a patient's clinical record displays a summary of all the hospital visits that have been recorded for that patient.

Click on the Clinical tab within a patient record and then select Admission History


 

Filtering Admission History

To filter Admission History, click Filter to reveal a drop-down list, and then click Last 6 Months or Last 12 Months.

Searching within the Admission History

To search for an Admission History, click the Search box and type in a keyword from the reason or the name of the hospital. Press Enter, and the system will display a list of the closest matches.

Adding an Admission History Record

1. To add a new Admission , click Add External Admission to open the admission form.
   
   
    

2. Click the Calendar Icon to select the date of admission. If you are unsure of the exact date, click Accurate To to reveal a drop down list, and select Month or Year.
   
   
    

3. To select the institution where the patient was treated, click Facility and type in the first few letters of the name, and the system will reveal a list of closest matches from your Contact List. Click to select the name of the hospital or institution.
   
   If the institution is not in your contacts list, just type in the name. You do not need to make a selection from the contacts list.
   
   
    

4. Click Length of Stay and select the number of days the patient stayed in hospital.
   
   Click Attendance Type to reveal a drop-down list and select whether they were an In-Patient, Out-Patient, Emergency or attending for the Day only.
   
   
    

5. Select the Provider, Reason and Procedure.
   
   Each of these fields will reveal a drop-down list of closest matches when you start typing text into them. If you cannot find what you are looking for, you do not have to make a selection from the list. Just use free text to type in the required details.
   
    

6. Click Comments and add any relevant clinical notes or comments, and then click Save once complete.
   
   

Inserting an Admission History in Today's Notes

If you want to add the Admission History to the notes of the current consultation, tick the Add to Today's Notes tick-box.

Making an Admission History Record Confidential

If you want to make the record confidential, so that only you can see it, click the Confidential tick-box.

The newly created Admission will now be masked and only viewable to the creator of the record in the Admission History summary.


To Open the Admission History, hover your mouse over the Facility name. When the mouse cursor changes to a Finger Pointer, click the Hospital name.
 

Editing an Admission History

To Edit an Admission, click the Tick-box next to the name to reveal a list of options. Click Edit to open the Admission form.


Update the form with all required details, and click Save to apply the changes.


 

Printing an Admission History Record

To Print an Admission History, click the Tick-box next to the name and click Print Icon to open a print preview.


Check to make sure the page is going to the right printer Destination, select the Layout and Color if required, and click Print.

Deleting an Admission History Record

To Delete an Admission, click the Tick-box and click Delete to permanently delete the Admission from the patient's record.


Click Yes to acknowledge the Admission will be deleted.



To Delete Multiple Admissions at once, click the Tick-boxes next to the name to reveal a list of options. Click Delete to permanently delete the Admissions from the patient's record.



Click Yes to acknowledge the Admissions will be deleted.