Observations

Observations

How to review and add observations about a patient. Observations may include either Physical, Pathology, or a variety of other observations.

The Observations page in a patient's clinical record displays a history of previous observations. which is viewable as individual records or plotted on a timeline graph.

To view the records from the different types of observations, click the Category and if available, Sub-category (in the below picture, Physical > BMI) and the observations will be displayed in the table on the right hand side.

To sort by each of the key points in the observation (In this example, Date, BMI, Unit, Recording Doctor, Created Date, Confidentiality), click on the relevant heading at the top of the table. In the below example, We've sorted by Date and oldest, denoted by an upwards triangle.

To Add a New Observation, click Add Observation to reveal a drop-down list of observations and click the Type of Observation (e.g. Vitals) to open an observation form.

Fill in the observation form with all required details. You do not need to complete the whole form - just fill in the details of the examination/s you have performed. Click Save once the observation is complete.

In order to retrieve full record of the observation, the results of the examination are automatically added to the consultation notes. This means that the Add to Today's Notes tick-box is always checked, and cannot be unchecked.

To add an observation from another category, like Pathology, click the Observation Category, and then click Add Observation, and select the observation from the drop-down list (e.g. Vitals).

To Edit Observation Results, select the Observation Category on the left-hand side, and click the Tick Box next to the record you wish to edit and click Edit.

The Sub-category of the observation will be directly editable from the record. Type in the new value and press Enter to save.

To Delete an Observation, select the Type of Examination on the left-hand side, click the Tick Box next to the record you want deleted and click Delete to permanently delete the observation from the patient's record.

Click Yes to acknowledge that the observation will be deleted.

To print a list of the Observation records, click Print.

To view the data with Percentiles attached (additionally with some categories, imperial units can be selected), click the relevant Tick-Box according to the below image.

Timeline Graph

Medirecords has the ability to show observation results over time in a timeline graph.

To access a timeline graph, click the relevant Observation Categories (e.g. Physical > Height) and click View > Timeline Graph.

You can now see the observations tracked over time, in this example BMI as a function of Year.

To Upload an Image to the grid, click Upload Image to open a file explorer. Click to select the image you want to upload.

To Display an Image on the grid, click the Show Image tick-box.

You are also able to view the graph using Imperial Values and Percentiles. Click the relevant tick box to use them.

To Print an Observation, click Print to open a print preview.

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

NOTE: Printing is handled by your browser. For information about Printing, including troubleshooting, please refer to the browser's support material.

To quickly locate a Mental Health Assessment, click on Mental Health and the following assessments that has been taken will be recorded here.

Mental Health Assessments are made in Today's Note, by clicking on New EPC, and choose DASS 21 or K-10 Assessment.

When an assessment has been completed in Today's Notes, it will populate in the Mental Health Observation section.

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