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Navigating and Managing the Admissions Module

Overview

This user guide offers a comprehensive overview of the Admissions module in MediRecords, detailing how to access the module, manage patient admissions, and navigate its core features. Whether you're recording a new admission, updating patient status, or reviewing encounter history, this guide supports users in efficiently managing inpatient workflows and ensuring accurate clinical documentation.

​Table of Contents

  1. 🎓 Managing Pre-Admission Appointments and Forms
    • Handle pre-admission appointments and registration
  2. 🎓 Navigating and Managing the Admissions Grid
    • View and manage all admissions from the admissions grid
  3. 🎓 How to Create a New Admission Encounter
    • Start a new admission for a patient
  4. 🎓 Managing Clinical Documentation for Admitted Patients
    • Document and update clinical notes during admission
  5. 🎓 How to Create a New Handover
    • Record and share shift changeover notes
  6. 🎓 How to Create New Progress Notes
    • Add ongoing progress notes
  7. 🎓 Viewing Patient Summary Information
    • Access a snapshot of key patient data
  8. 🎓 Accessing Admission Notes
    • Open and review notes related to the admission
  9. 🎓 Charting Adult Deterioration Detection System (ADDS)
    • Record and monitor vital signs to detect early signs of patient deterioration
  10. 🎓 Charting Fluid Balance
    • Track fluid input and output to manage patient hydration and treatment plans
  11. 🎓 Charting Neurovascular
    • Document neurovascular observations to assess circulation, movement, and sensation
  12. 🎓 Creating and Completing Patient Assessments
    • Initiate and document clinical assessments to support patient care planning
  13. 🎓 Managing and Creating Patient Letters
    • Generate letters directly from the patient admission record
  14. 🎓 Uploading and Managing Patient Attachments
    • Add external documents and files in the patient record
  15. 🎓 Viewing Patient Admission History
    • Access a list of previous and current admissions for a patient
  16. 🎓 Discharging a Patient
    • Complete the discharge process and update the patient’s admission status
🎓 Managing Pre-Admission Appointments and Forms
 
 
ℹ️ Please note that pre-admission appointments need to be enabled for your practice. If this has not been done, refer to the steps outlined in the User Guide: Configuring Admissions Facility Settings.
 

1. Click New Appointment from the Appointment Calendar.

 

Click New Appointment from the Appointment Calendar.
ℹ️ The New Appointment form will appear. Complete all required fields following the standard appointment scheduling process. The steps below will highlight the key differences when scheduling a pre-admission appointment, which vary from the usual process.

 

2. If applicable, to add a referral, click the drop-down arrow next to the Referral field.

 

If applicable, to add a referral, click the drop-down arrow next to the Referral field.
 

3. Choose the referral you want to add from the populated list.

 

Choose the referral you want to add from the populated list.
ℹ️ The referral displayed in this list includes any referral previously added in the Patient Record under Details Tab > Demographics > Referral section. If you are adding a referral for the first time, you can do so by clicking the + symbol.

 

4. In the Type field, click to select from the available Appointment Types listed.

 

In the Type field, click to select from the available Appointment Types listed.
 

5. Select Pre-admission.

 

Select Pre-admission.
ℹ️ The Pre-Admission Appointment Type will be available here if Pre-Admissions has been enabled in the Admissions Configuration Grid.

 

6. Click on Save

 

Click on Save
 

7. To complete the pre-admissions form, find the booked Appointment in the Appointment Calendar and click on it to open.

 

To complete the pre-admissions form, find the booked Appointment in the Appointment Calendar and click on it to open.
 

8. Click on Pre-admission Form.

 

Click on Pre-admission Form.
 

9. Enter in a Reason for Presentation.

 

Enter in a Reason for Presentation.
 

10. Select the appropriate option from the populated choices.

 

Select the appropriate option from the populated choices.
 

11. Click the drop-down arrow in the Attendance Type field to view the list of options to choose from.

 

Click the drop-down arrow in the Attendance Type field to view the list of options to choose from.
 

12. Select your choice from the options listed.

 

Select your choice from the options listed.
 

13. Enter the procedure(s) in the designated field.

 

Enter the procedure(s) in the designated field.
 

14. Select the appropriate option from the listed choices.

 

Select the appropriate option from the listed choices.
 

15. Click the calendar icon to choose the Expected Admission Date.

 

Click the calendar icon to choose the Expected Admission Date.
 

16. Click the clock icon to select the Expected Admission Time.

 

Click the clock icon to select the Expected Admission Time.
 

17. Add any relevant comments, if applicable.

 

Add any relevant comments, if applicable.
 

18. If applicable, and the patient is ready to admit, you can check the box here.

 

If applicable, and the patient is ready to admit, you can check the box here.
 

19. Click on Save to confirm.

 

Click on Save to confirm.
 

20. A pop-up will appear indicating that the form has been saved successfully.

 

A pop-up will appear indicating that the form has been saved successfully.
 

21. Click on Save to confirm.

 

Click on Save to confirm.
 

22. Alternatively, you can complete the Pre-Admission Registration form from the Patient Record by hovering over the booked appointment and clicking the patient's name.

 

Alternatively, you can complete the Pre-Admission Registration form from the Patient Record by hovering over the booked appointment and clicking the patient's name.
 

23. In the Clinical Tab under Today's Notes, select Pre-Admission.

 

In the Clinical Tab under Today's Notes, select Pre-Admission.
 

24. Complete the Pre-Admission Registration form as detailed in steps 9-19 above.

 

ℹ️ Once the pre-admission form is completed, the patient will be added to the Admissions Grid. If the Patient is Ready to Admit box was checked, the status will appear as Ready to Admit. Otherwise, the status will display as Pre-Admission.
 
For more information about the Admissions Grid, please refer to the steps outlined in Navigating and Managing the Admissions Grid.

🎓 Navigating and Managing the Admissions Grid

 

25. From the Navigation Menu, click on Admissions.

 

From the Navigation Menu, click on Admissions.
 

26. By default, this field will display as All Wards, No Ward View. Click on this field to adjust your filter settings.

 

By default, this field will display as All Wards, No Ward View. Click on this field to adjust your filter settings.
 

27. Choose from the displayed options to modify your view.

 

Choose from the displayed options to modify your view.
 

28. When you select a single option, an icon will appear, allowing you to add a note for that ward. Click on this icon to enter your note.

 

When you select a single option, an icon will appear, allowing you to add a note for that ward. Click on this icon to enter your note.
 

29. Enter your note in the provided field.

 

Enter your note in the provided field.
 

30. Select a colour.

 

Select a colour.
 

31. Click on Save to confirm.

 

Click on Save to confirm.
 

32. When you hover your mouse over the colored dot, your note for that ward will be displayed.

 

When you hover your mouse over the colored dot, your note for that ward will be displayed.
 

33. You can edit this note by clicking the pencil icon.

 

You can edit this note by clicking the pencil icon.
 

34. Make the necessary changes here; you can edit your note and/or select a different colour. If you wish to delete this note, click the trash can icon. Once you are finished, click Save to confirm your changes.

 

Make the necessary changes here; you can edit your note and/or select a different colour. If you wish to delete this note, click the trash can icon. Once you are finished, click Save to confirm your changes.
 

35. This field displays a tally of the occupied and vacant beds, as well as the total number of beds.

 

This field displays a tally of the occupied and vacant beds, as well as the total number of beds.
 

36. Clicking into the field will provide more detailed information.

 

Clicking into the field will provide more detailed information.
 

37. You can use the Search field to find patients in the Admissions Grid.

 

You can use the Search field to find patients in the Admissions Grid.
 

38. Click on Filter for advanced filtering options.

 

Click on Filter for advanced filtering options.
 

39. Make the necessary changes here to refine your search.

 

Make the necessary changes here to refine your search.
ℹ️ Please note that the default statuses are:
  • Admitted
  • Emergency
  • Ready to Discharge

If your practice has Pre-Admissions enabled, you will need to add the following statuses:

  • Pre-Admission 
  • Ready to Admit

 

40. Click on Apply to confirm.

 

Click on Apply to confirm.
 

41. Click on the ellipsis in the header column to customise your columns.

 

Click on the ellipsis in the header column to customise your columns.
 

42. Make any necessary changes here and click Apply to confirm.

 

Make any necessary changes here and click Apply to confirm.
 

43. In the Status column, you can click on the status to update it as needed.

 

In the Status column, you can click on the status to update it as needed.
 

44. Select the applicable option from the provided choices.

 

Select the applicable option from the provided choices.
 

45. Hovering your mouse over the information icon will enable you to view an audit of the user who created and/or updated the admission.

 

Hovering your mouse over the information icon will enable you to view an audit of the user who created and/or updated the admission.
 

46. Click on the ellipsis to the far right of the patient listed in the grid.

 

Click on the ellipsis to the far right of the patient listed in the grid.
 

47. This will enable you to record the handover or move the patient to another ward, room, and/or bed.

 

This will enable you to record the handover or move the patient to another ward, room, and/or bed.

 

🎓 How to Create a New Admission Encounter

 

48. From the Navigation Menu, click on Admissions.

 

From the Navigation Menu, click on Admissions.
 

49. Click on Add Admission, which is located to the far right above the grid.

 

Click on Add Admission, which is located to the far right above the grid.
 

50. Search for the patient you want to add in the Search Patient field.

 

Search for the patient you want to add in the Search Patient field.
 

51. Click on Search.

 

Click on Search.
 

52. Click the + symbol to create a New Encounter.

 

Click the + symbol to create a New Encounter.
 

53. Select the option that applies from the displayed choices.

 

Select the option that applies from the displayed choices.
 

54. The Admission form will appear for completion. Make sure to fill in all mandatory fields marked with an asterisk before saving.

 

The Admission form will appear for completion. Make sure to fill in all mandatory fields marked with an asterisk before saving.
 

55. Click on the Reason for Presentation field and enter the reason for presentation, then select the option that applies.

 

Click on the Reason for Presentation field and enter the reason for presentation, then select the option that applies.
ℹ️ This field uses SNOMED-coded values; select the option that applies.

 

56. Click on the Specialty field and enter the specialty, then select the option that applies.

 

Click on the Specialty field and enter the specialty, then select the option that applies.
ℹ️ If this is an Emergency, the additional field that applies is Triage, with the following options:
  • Yes
  • No
  • N/A

Make the appropriate selection here to reflect the situation.

 

57. Click on the Intended LOS (Length of Stay) field, then select the option that applies.

 

Click on the Intended LOS (Length of Stay) field, then select the option that applies.
 

58. Click on the Attendance Type field, then select the option that applies.

 

Click on the Attendance Type field, then select the option that applies.
ℹ️ Inpatient: Patient is hospitalised and stays overnight.
Outpatient: Patient receives care without overnight hospitalisation.
Emergency: Encounter occurs in the Emergency Department.
Home: Practitioner visits the patient at home.
Field: Encounter takes place outside the usual care setting.
Day Only: Patient requires extended treatment without overnight stay.
Virtual: Encounter occurs remotely via electronic communication.
Other: Any encounter type not covered above, with an extension to specify the type.

 

59. Click on the Attending Provider field.

 

Click on the Attending Provider field.
 

60. Enter the name of the Attending Provider, then select the option that applies.

 

Enter the name of the Attending Provider, then select the option that applies.
ℹ️ Returns a list of clinical users within the tenant, as well as health professionals from the tenant's contact list.

 

61. Click on the Mode of Admission field, then select the option that applies.

 

Click on the Mode of Admission field, then select the option that applies.
ℹ️ Admitted Patient Transferred from Another Hospital: A patient who has been formally admitted to the current hospital after being transferred from a different healthcare facility.
Statistical Admission: An admission recorded for statistical purposes, often used for data collection and analysis, but may not involve direct patient care.
Other: Any admission type that does not fit into the defined categories, requiring further clarification or specification.

 

62. Click on the Admission/Transfer Source field.

 

Click on the Admission/Transfer Source field.
 

63. Then, select the applicable option.

 

Then, select the applicable option.
 

64. Click on the Referring Facility field.

 

Click on the Referring Facility field.
 

65. Enter the name of the Referring Facility, then select the option that applies.

 

Enter the name of the Referring Facility, then select the option that applies.
ℹ️ Returns a list of service providers from the tenant's Contact List.

 

66. Click on the Referring Doctor field.

 

Click on the Referring Doctor field.
 

67. Enter the name of the Referring Doctor, then select the option that applies.

 

Enter the name of the Referring Doctor, then select the option that applies.
ℹ️ Returns a list of Health Professionals from the tenant's Contact List.

 

68. Click on the Usual GP field.

 

Click on the Usual GP field.
 

69. Enter the name of the Usual GP, then select the option that applies.

 

Enter the name of the Usual GP, then select the option that applies.
ℹ️ Returns a list of Health Professionals from the tenant's Contact List.

 

70. Click on the Facility field.

 

Click on the Facility field.
 

71. Make your selection from the option that applies.

 

Make your selection from the option that applies.
ℹ️ This provides a list of practices within the tenant. Your selection here indicates the facility to which the patient will be admitted.

 

72. Click on the Ward field.

 

Click on the Ward field.
 

73. Make your selection from the option that applies.

 

Make your selection from the option that applies.
 

74. Click on the Room field.

 

Click on the Room field.
 

75. Make your selection from the option that applies.

 

Make your selection from the option that applies.
 

76. Click on the Bed field.

 

Click on the Bed field.
 

77. Make your selection from the option that applies.

 

Make your selection from the option that applies.
 

78. Select the Admission Date field and enter the appropriate date.

 

Select the Admission Date field and enter the appropriate date.
 

79. Select the Admission Time field and enter the appropriate time.

 

Select the Admission Time field and enter the appropriate time.
ℹ️ By default, the Admission Date and Time will automatically populate with the current date and time.

 

80. Select the Estimated Discharge Date field and enter the date, if applicable.

 

Select the Estimated Discharge Date field and enter the date, if applicable.
 

81. Select the Comments field and enter any relevant comments, if applicable.

 

Select the Comments field and enter any relevant comments, if applicable.
 

82. Click on Save to confirm.

 

Click on Save to confirm.
 

83. A pop-up will confirm that the new encounter for the patient has been created.

 

A pop-up will confirm that the new encounter for the patient has been created.
ℹ️ The patient’s name will appear in the Admissions Grid with a corresponding status based on the encounter type selected:
  • Planned: Admitted Status
  • Urgent: Admitted Status
  • Emergency: Emergency Status
ℹ️ If you are deleting the note at this step, a pop-up will appear asking if you are sure you want to delete it. Select Yes to confirm the deletion.
ℹ️ A minimum of 2 characters is required for the search to function. If no records are found, the grid will show No items to display.
ℹ️ Filtering allows you to sort by status and/or date range. The default statuses are Admitted, Emergency, and Ready to Discharge.
ℹ️ If you change the status from Emergency, the option to select Admit will be available. If you change the status from Pre-Admitted, the options to select Ready to Admit and Cancel will be available.

ℹ️ Handover occurs when the responsibility for a patient's care is transferred from one healthcare provider or team to another. This typically happens during transitions of care, such as:

  • User to user during shift changes
  • Transfer between hospital units
  • Discharge from one healthcare facility and admission to another
For instructions on how to perform a Handover, please refer to step 88.

 

🎓 Managing Clinical Documentation for Admitted Patients

 

84. Click on the patient's name to access their admission record.

 

Click on the patient's name to access their admission record.
ℹ️ Alternatively, you can access a patient's current admission from the Patient Record, where you will find the Admissions tab. This option is available if Admissions has been enabled for the practice you are viewing the record from.

 

85. The patient record header bar displays the same icons found in the standard version without admissions. Hovering your mouse over the icons will reveal any recorded data for the patient.

 

The patient record header bar displays the same icons found in the standard version without admissions. Hovering your mouse over the icons will reveal any recorded data for the patient.
ℹ️ The available tabs within the patient record are also consistent with the standard version, with the added distinction of an Admissions tab for patients who have been admitted.

 

86. The second header bar displays the quick actions available when clinically documenting information.

 

The second header bar displays the quick actions available when clinically documenting information.
ℹ️ The following Quick Actions are available for clinically documenting information:
  • New Handover: Create a new handover when a patient's care is transferred from one healthcare provider or team to another.
  • Progress Notes: Add patient progress notes to track clinical observations and treatments.
  • Pathology Request: Initiate a request for pathology tests for the patient.
  • Radiology Request: Request radiology imaging or diagnostic tests for the patient.
  • New Letter: Generate a new letter, such as referral or discharge letters, for the patient.
  • New Attachment: Upload and attach relevant documents or files related to the patient's care.
  • View Messages: Access and review messages related to the patient’s care in the Secure Messaging section/Provider Inbox.

 

🎓 How to Create a New Handover

 

87. To create a new handover using the quick actions, click on the icon.

 

To create a new handover using the quick actions, click on the icon.
 

88. Alternatively, a New Handover can be initiated from the Admissions Grid by clicking on the ellipsis next to the relevant admission and selecting Handover from the options.

 

Alternatively, a New Handover can be initiated from the Admissions Grid by clicking on the ellipsis next to the relevant admission and selecting Handover from the options.
 

89. In the Handover Type field, click on the drop-down arrow to display a list of available options.

 

In the Handover Type field, click on the drop-down arrow to display a list of available options.
ℹ️ The default option that displays in this field is based on the Users Security Role:
  • Nurse - Nursing
  • Employee Doctor - Medical
  • Guest - Other
  • Receptionist - Other
  • Allied Health Professional - Other
  • Practice Owner - Other
  • Practice Manager - Other
This selection is automatically pre-set, but you can choose an alternative type from the drop-down menu if needed.

 

90. Make the appropriate selection from the options provided.

 

Make the appropriate selection from the options provided.
ℹ️ This allows you to select the appropriate handover type for the patient’s admission.

 

91. In the Handover Mode, click on the drop-down arrow to display a list of available options.

 

In the Handover Mode, click on the drop-down arrow to display a list of available options.
 

92. Make the appropriate selection from the options provided.

 

Make the appropriate selection from the options provided.
ℹ️ The default option in the Handover Type field is Face to Face. This selection is automatically pre-set, but you can choose an alternative type from the drop-down menu if needed.

 

93. In the Attending Provider field, if the pre-populated user differs from the intended provider, you can click the X to remove the default selection. Alternatively, if the field is blank, you can manually type in the desired user's name to add them as the attending provider.

 

In the Attending Provider field, if the pre-populated user differs from the intended provider, you can click the X to remove the default selection. Alternatively, if the field is blank, you can manually type in the desired user's name to add them as the attending provider.
ℹ️ The Attending Provider field defaults to the attending consultant chosen from the Admission form. If no consultant has been selected, the field will remain blank. When adding a contact to a blank Attending Provider field, the system will pull names from the existing contacts within the tenant, allowing you to select the appropriate provider.

 

94. In the Patient Status options, the default selection will be set to Stable. If applicable, click on Deteriorating to update the status.

 

In the Patient Status options, the default selection will be set to Stable. If applicable, click on Deteriorating to update the status.
 

95. Enter a Subject name

 

Enter a Subject name
 

96. Free type in the relevant information.

 

Free type in the relevant information.
ℹ️ Includes the SBOAR sections, so users can write their comments for each area:
  • Situation
  • Background
  • Observation
  • Assessment
  • Recommendation

 

97. Enter the name of the User who will be receiving the Handover.

 

Enter the name of the User who will be receiving the Handover.
ℹ️ The Received By and Password fields are used to formally hand over care to another user. If this is not applicable, you can skip ahead to step 101.

 

98. The receiving User will need to enter their MediRecords login password here.

 

The receiving User will need to enter their MediRecords login password here.
ℹ️ A warning pop-up message will appear if the user enters an incorrect password.

 

99. Click Verify to validate the password.

 

Click Verify to validate the password.
 

100. A pop-up will appear confirming that the account has been verified.

 

A pop-up will appear confirming that the account has been verified.
 

101. Click on Handover to confirm.

 

Click on Handover to confirm.
 

102. A pop-up message will appear asking you to confirm the submission of the handover. Click Yes to confirm.

 

A pop-up message will appear asking you to confirm the submission of the handover. Click Yes to confirm.
ℹ️ Please note once you submit the handover you will not be able to edit.

 

103. A pop-up will appear confirming that the handover has been saved successfully.

 

A pop-up will appear confirming that the handover has been saved successfully.
ℹ️ The Handover will display for viewing in the Admissions Notes section.

 

🎓 How to Create New Progress Notes

 

104. To create New Progress Notes using the quick actions, click on the icon.

 

To create New Progress Notes using the quick actions, click on the icon.
 

105. In the Type field, click on the drop-down arrow to display a list of available options.

 

In the Type field, click on the drop-down arrow to display a list of available options.
 

106. Make the appropriate selection from the options provided.

 

Make the appropriate selection from the options provided.
 

107. In the Clinical Type, click on the drop-down arrow to display a list of available options.

 

In the Clinical Type, click on the drop-down arrow to display a list of available options.
 

108. Select Diagnosis.

 

Select Diagnosis.
 

109. In the Clinical Options field, enter in a diagnosis.

 

In the Clinical Options field, enter in a diagnosis.
 

110. Click on Add to confirm.

 

Click on Add to confirm.
ℹ️ When you click Add, the diagnosis will populate under the Diagnosis heading in the Progress Notes.

 

111. Enter a Subject name.

 

Enter a Subject name.
 

112. Utilise the formatting toolbar if applicable.

 

Utilise the formatting toolbar if applicable.
ℹ️ By default the notes will display in SOAP order.
  • Subjective – The patient's reported symptoms, concerns, and personal experiences.
  • Objective – Observable data, such as vital signs, physical exam findings, and test results.
  • Assessment – The clinician's interpretation or diagnosis based on the subjective and objective information.
  • Plan – The course of action, including treatments, tests, referrals, or follow-up care.

 

113. In the Progress Notes field, you can freely type your notes.

 

In the Progress Notes field, you can freely type your notes.
 

114. Click on Save to confirm.

 

Click on Save to confirm.
 

115. A pop-up message will appear asking you to confirm the submission of the Progress Notes. Click Yes to confirm.

 

A pop-up message will appear asking you to confirm the submission of the Progress Notes. Click Yes to confirm.
ℹ️ Please note once you submit the Progress Notes you will not be able to edit.

 

116. A pop-up will appear confirming that the note has been saved successfully.

 

A pop-up will appear confirming that the note has been saved successfully.
ℹ️ The Progress Notes will display for viewing in the Admissions Notes section.

 

🎓 Viewing Patient Summary Information

 

117. Click on Summary to view a summary of the pre-recorded data.

 

Click on Summary to view a summary of the pre-recorded data.

 

🎓 Accessing Admission Notes

 

118. Click on Admission Notes to display the admission form, handover notes, and progress notes that have been pre-recorded for the current admission.

 

Click on Admission Notes to display the admission form, handover notes, and progress notes that have been pre-recorded for the current admission.

 

🎓 Charting Adult Deterioration Detection System (ADDS)

 

119. Click on Charting to open the sub-menus available in this section.

 

Click on Charting to open the sub-menus available in this section.
 

120. Click on ADDS to record the relevant clinical information.

 

Click on ADDS to record the relevant clinical information.
ℹ️ By default, you will be directed to the Observations view.

 

121. Click the + icon to add a new ADDS entry.

 

Click the + icon to add a new ADDS entry.
 

122. Enter the applicable data in the provided fields.

 

ℹ️ The Adult Deterioration Detection System (ADDS) records key physiological observations (Vital Signs) at the point of care, captured over time during the patient’s episode. The observations included in this chart are:
  • Respiratory Rate
  • O2 Saturation Rate
  • O2 Flow Rate
  • FIO2 (%)
  • Oxygen Device
  • Blood Pressure
  • Heart Rate
  • Temperature
  • Consciousness
  • Pain Score
  • Intervention
The system tracks and triggers alerts for chart types that may prompt a clinical response when patient deterioration is observed. Each observation can be linked to an escalation protocol to guide users on the appropriate actions to take based on the recorded values.

 

123. If an intervention needs to be recorded, click the + icon in the Intervention field.

 

If an intervention needs to be recorded, click the + icon in the Intervention field.
 

124. Each escalation includes a checklist to guide users on the appropriate actions to take when a patient falls outside the normal range. Below are the actions required/protocols for the ADDS based on each escalation:

 

Each escalation includes a checklist to guide users on the appropriate actions to take when a patient falls outside the normal range. Below are the actions required/protocols for the ADDS based on each escalation:
 

125. Select the applicable option in the Actions Required section.

 

Select the applicable option in the Actions Required section.
 

126. Enter a description in the provided field.

 

Enter a description in the provided field.
 

127. Click on Save to confirm.

 

Click on Save to confirm.
 

128. Click the tick icon to save the recorded data.

 

Click the tick icon to save the recorded data.
 

129. If you need to delete your entry, click the ellipse.

 

If you need to delete your entry, click the ellipse.
 

130. Click on Delete.

 

Click on Delete.
 

131. In the comments section, record your reason for deletion.

 

In the comments section, record your reason for deletion.
 

132. Click on Save to confirm.

 

Click on Save to confirm.
 

133. Your deleted entry will be displayed with a red line, and all data will be greyed out in the column.

 

Your deleted entry will be displayed with a red line, and all data will be greyed out in the column.
 

134. Once there is recorded data, you can switch your view to Charts.

 

Once there is recorded data, you can switch your view to Charts.

 

🎓 Charting Fluid Balance

 

135. Click on Fluid Balance to enter your data.

 

Click on Fluid Balance to enter your data.
 

136. Click on the + icon to add a new Fluid Balance entry.

 

Click on the + icon to add a new Fluid Balance entry.
ℹ️ A fluid balance chart records a patient’s fluid intake and output over a 24-hour period, aiding clinical decisions by medical staff, nurses, and dieticians.

 

137. Input the relevant data into the designated fields and click the checkmark to save your changes.

 

Input the relevant data into the designated fields and click the checkmark to save your changes.
 

138. The entered data will be displayed, and a confirmation pop-up will appear to indicate that the data has been successfully saved.

 

The entered data will be displayed, and a confirmation pop-up will appear to indicate that the data has been successfully saved.
 

139. If you need to delete your entry, click the ellipse.

 

If you need to delete your entry, click the ellipse.
 

140. Click on Delete.

 

Click on Delete.
 

141. In the comments section, record your reason for deletion.

 

In the comments section, record your reason for deletion.
 

142. Click on Save to confirm.

 

Click on Save to confirm.
 

143. The Date Picker allows you to navigate past recordings, defaulting to display the current day.

 

The Date Picker allows you to navigate past recordings, defaulting to display the current day.
 

144. You can review the Positive Balance, Negative Balance, and Fluid Restriction here.

 

You can review the Positive Balance, Negative Balance, and Fluid Restriction here.
ℹ️ Positive Balance
  • Description: A read-only, auto-generated field.
  • Calculation: Calculated as (Progressive Total Intake Volumes - Progressive Total Output Volumes). If positive, it displays in this field; otherwise, it remains blank.
Negative Balance
  • Description: A read-only, auto-generated field.
  • Calculation: Calculated as (Progressive Total Intake Volumes - Progressive Total Output Volumes). If negative, it displays in this field; otherwise, it remains blank.
Fluid Restriction
  • Description: An input field, initially blank with placeholder text 'ml'.
  • User Input: Accepts values starting from 0, no upper limit, whole numbers only, no decimals.
  • Features: Can be cleared by the user. Prepopulated with the most recent completed grid's saved value.

 

🎓 Charting Neurovascular

 

145. Click on Neurovascular.

 

Click on Neurovascular.
ℹ️ A Neurovascular Chart is a tool used to assess and monitor a patient's neurological and vascular status, helping detect abnormalities or changes in the nervous system and blood vessels.

 

146. Select the appropriate body part from the displayed tabs for assessment.

 

Select the appropriate body part from the displayed tabs for assessment.
ℹ️ The 4 limbs include:
  • LU - Left Upper Limb
  • RU - Right Upper Limb
  • LL - Left Lower Limb
  • RL - Right Lower Limb

 

147. Click the + icon to add a new Neurovascular entry.

 

Click the + icon to add a new Neurovascular entry.
 

148. Input the relevant data into the designated fields and click the checkmark to save your changes.

 

Input the relevant data into the designated fields and click the checkmark to save your changes.
ℹ️ Please note that these fields are drop-down selections.

 

149. The entered data will be displayed, and a confirmation pop-up will appear to indicate that the data has been successfully saved.

 

The entered data will be displayed, and a confirmation pop-up will appear to indicate that the data has been successfully saved.
 

150. If you need to delete your entry, click the ellipse.

 

If you need to delete your entry, click the ellipse.
 

151. Click on Delete.

 

Click on Delete.
 

152. In the comments section, record your reason for deletion.

 

In the comments section, record your reason for deletion.
 

153. Click on Save to confirm.

 

Click on Save to confirm.
 

154. The Date Picker allows you to navigate past recordings, defaulting to display the current day.

 

 

🎓 Creating and Completing Patient Assessments

 

155. Click on Assessments.

 

Click on Assessments.
 

156. Click on New Assessment.

 

Click on New Assessment.
 

157. Select from the available assessments.

 

Select from the available assessments.
 

158. Complete the mandatory fields with valid inputs to enable the Finalise button.

 

Complete the mandatory fields with valid inputs to enable the Finalise button.
ℹ️ Once the assessment is finalised, it cannot be reverted to draft status. The completed assessment will appear in the Assessments Grid for viewing.

 

🎓 Managing and Creating Patient Letters

 

159. Click on Letters.

 

Click on Letters.
 

160. Click on New Letter.

 

Click on New Letter.
 

161. Make sure to complete all mandatory fields in the Letter Builder.

 

Make sure to complete all mandatory fields in the Letter Builder.
 

162. In the Template field, search for a pre-created letter template to use, such as the Discharge Summary.

 

In the Template field, search for a pre-created letter template to use, such as the Discharge Summary.
 

163. Select from the options that are populated.

 

Select from the options that are populated.
ℹ️ Letter Templates are stored under Resources > Letter Templates. Please note that you will need to know the name of the template stored in this section in order to use it.

 

164. Click the drop-down arrow next to the Recipient Contact Type and make the appropriate selection.

 

Click the drop-down arrow next to the Recipient Contact Type and make the appropriate selection.
 

165. Click on Save to confirm.

 

Click on Save to confirm.
 

166. Your letter template will generate with the relevant patient information

 

Your letter template will generate with the relevant patient information
 

167. Once ready, click Finalise to save your changes.

 

Once ready, click Finalise to save your changes.
 

168. A pop-up will appear confirming the saved changes.

 

A pop-up will appear confirming the saved changes.
 

169. Click on Close to exit the Letter Writer.

 

Click on Close to exit the Letter Writer.
 

170. You can view and open the letter from the Letters Grid by clicking on the subject name.

 

You can view and open the letter from the Letters Grid by clicking on the subject name.
 

171. By default, letters are saved with a status of Draft. To change the status, click on the status and switch it to Final.

 

By default, letters are saved with a status of Draft. To change the status, click on the status and switch it to Final.
ℹ️ Alternatively, if a letter is in Final status and you need to edit it, you must first change the status to Draft. No changes can be made while the letter is in Final status.

 

🎓 Uploading and Managing Patient Attachments

 

172. Click on Attachments.

 

Click on Attachments.
 

173. Click on New Attachments.

 

Click on New Attachments.
 

174. From the Category field, click on the drop-down extender to display the list of available categories.

 

From the Category field, click on the drop-down extender to display the list of available categories.
 

175. Make the appropriate selection from the options provided in the drop-down list.

 

Make the appropriate selection from the options provided in the drop-down list
 

176. Click on Select Files to upload the correspondence from the saved destination on your computer.

 

Click on Select Files to upload the correspondence from the saved destination on your computer.
 

177. Your file will upload, and a File Successfully Uploaded message will be displayed in green.

 

Your file will upload, and a File Successfully Uploaded message will be displayed in green.
 

178. Click on Attach to confirm.

 

Click on Attach to confirm.
 

179. A pop-up will appear indicating All attachments have been successfully saved.

 

A pop-up will appear indicating All attachments have been successfully saved.
 

180. You can click on the ellipsis (three dots) to choose options such as Print or Delete the attachment.

 

You can click on the ellipsis (three dots) to choose options such as Print or Delete the attachment.
 

181. Make the appropriate selection from the options provided in the list.

 

Make the appropriate selection from the options provided in the list.
 

182. To view an attachment, click on the File Name where your attachment is listed.

 

To view an attachment, click on the File Name where your attachment is listed.

 

🎓 Viewing Patient Admission History

 

183. Click on Admission History.

 

Click on Admission History.
 

184. In the Admission History Grid, a history of the patient's admissions will be displayed. The status will appear above the grid to the right.

 

In the Admission History Grid, a history of the patient's admissions will be displayed. The status will appear above the grid to the right.
ℹ️ Clicking on a current admission will redirect you to the Summary Tab, where you can view further details related to the admission.

 

🎓 Discharging a Patient

Steps 185–187 outline three alternative methods for discharging a patient.

 

185. Click the New Discharge Form icon located within the patient's Admission tab.

 

Click the New Discharge Form icon located within the patient's Admission tab.
 

186. Alternatively, you can click where it displays as Admitted and select Ready to Discharge.

 

Alternatively, you can click where it displays as Admitted and select Ready to Discharge.
 

187. Alternatively this can be done from the Admissions Grid.

 

Alternatively this can be done from the Admissions Grid.
 

188. Select the Discharge Destination by clicking the drop-down arrow.

 

Select the Discharge Destination by clicking the drop-down arrow.
 

189. Make your selection that is appropriate from the options displayed.

 

Make your selection that is appropriate from the options displayed.
 

190. Input the discharge date and time.

 

Input the discharge date and time.
 

191. Select the Discharge Destination by clicking the drop-down arrow.

 

Select the Discharge Destination by clicking the drop-down arrow.
 

192. Select the most appropriate option from the choices displayed.

 

Select the most appropriate option from the choices displayed.
 

193. Type the Discharge Reason into the designated field.

 

Type the Discharge Reason into the designated field.
 

194. Use the Recommendations section as a checklist to guide your discharge planning.

 

Use the Recommendations section as a checklist to guide your discharge planning.
 

195. Click on New Letter to generate a Discharge Letter, if required.

 

Click on New Letter to generate a Discharge Letter, if required.
 

196. Make sure to tick the Discharge Summary checkbox, as this is a mandatory field.

 

Make sure to tick the Discharge Summary checkbox, as this is a mandatory field.
 

197. Select Discharge to finalise and confirm the process.

 

Select Discharge to finalise and confirm the process.
 

198. A pop-up will appear to confirm that the patient's status has been updated to discharged.

 

A pop-up will appear to confirm that the patient's status has been updated to "discharged.
 
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