Clinical information is saved in the patient's history and summaries.
History View
Clinical Records is used to run consultations, record information and access Zedmed's clinical features. This guide explains the History View, which displays information recorded using Zedmed's clinical notes and modules.
The information can be searched and filtered as explained in the functionality section below.
• Headings: Each encounter starts with a date, time and duration in bold.
• Colours: Notes= black | RFE = green | Problem = red | Scripts & referrals = blue.
Search for specific information
Select the Search History button, enter a term and select Find Next.
Note- this Searches the range in the Visible field.
Filter what is displayed
Adjust the amount of detail shown
Select the 1, 2 and 3 buttons to increase or decrease the level of detail shown.
Period shown
Select Last 10 , Last 1 Year, 3 Years or All in the Visible field's drop-down to set the period shown.
Include MHR uploads
Toggle the button on to show information added to the patient's MyHealthRecord by other providers.
Filter by a specific problem, medication or allergy
a) In Summary views, select the Problems, Allergies, Pregnancy or Medications tab.
b) Right-click a specific entry and select Filter History View to these Encounter Segments.
Update what is displayed
Add Further Notes
To add an addendum to a previous consult, right-click the bold encounter heading and select Add Notes.
Remove/delete notes
Up until midnight on the day the information was recorded, you can reopen the encounter. Any changes made, including the removal of clinical notes, will be reflected in the History View.
Add Problem/RFE
To add to a previous consult, right-click the text (red or green) and select Define Problem.
Add information from current encounter
Selecting the refresh icon will add information from the Current Encounter.
Reprint/Rename a referral
A referral, right-click the blue referral text and select open or rename.
Summary Views
Summary Views provide access to all files and information recorded for the patient. Right-click options are available for most items and give access to functions such as open, view, send and action.
Summary Views
Summary Views are for specific clinical modules and file management.
- Problems - Lists all problems recorded using the Problems module.
- Referrals (SS) - All referrals and their status (Open/Closed); grouped as pathology, radiology and letters.
- Results (MHR) (SS) (P) - All results and their status (Initial, Pending, Complete).
- Immunisations (MHR) - All Immunisations given and their date.
- Allergies (MHR) - The patient's recorded allergies.
- Measurements - A summary of the information recorded in the Measurement module.
- Medications - All prescriptions added in Zedmed's Drugs module.
- Images (SS) (P) - All images uploaded or scanned for the patient
- Incoming documents (P) - All letters scanned or uploaded for the patient.
- Documents (P) - All letters written or uploaded for the patient.
- Attachments (SS) (P) - All files of any type uploaded to the patient.
Summary View options
The codes MHR, SS and P are used in the list above to show where these options are available.
MyHealthRecord (MHR)
The Results, Immunisations and Allergies tabs have an Include MHR icon that can be toggled on and off to include information uploaded by other healthcare providers. MHR information appears with an Australia icon (screenshot above), and you can double-click any record to open it in ZedMed's viewer.
Secure Send (SS)
Secure Send allows you to send files to patients from Images, Attachments and Results (Zedmed v37 and later) and Referrals. To use Secure Send, right-click the file and select Send to Patient.
Paperclip (P)
Results, Images, Documents, Attachments and Incoming Documents have a paperclip icon to upload files to that Summary View. To add a file, select the paperclip and browse for the file's location.
