Zedmed's Clinical Records screen makes it easy to review and update clinical information and manage consultations. The menus and sections provide easy access to patient information and key features.
Opening a patient displays their information in the Demographics section (under their name), Summary Views, Reference View and History View. When an encounter starts, the Current Encounter section opens with the clinical modules, and the REF and clinical notes fields. To learn more, see recording clinical information.
Clinical Record menus
The top menu gives access to information and resources, and the main icon menu provides easy access to key features.
For a full list of menu items, see the Clinical Records details page.
Top Menu
- Most menu items provide another way to access key feature such as R
- Tools - gives access to the My Options screen where you can make customisations to your default settings, documents and layouts
- Clinical WP Setup is where you can update your clinical templates.
Main menu:
- Open Patient - Open a patient's record and access the functionality of the Current Encounter screen. Learn more.
- Waiting Room - View patients waiting to be seen. Admit a patient to open their record and start an encounter. Learn more.
- Results Inbox - View pathology and radiology results, and any letters that need to be actioned. Learn more.
- To Do List - The doctor's personal planner, which can be linked to the Patient’s To Do List. Learn more.
- Intramail (F7) - For internal messaging. Messages can be linked to a patient's record and added to their history. Learn more.
Demographics
This section contains patient demographics, including Medicare card and Health Care card details. There is also an icon to access the Patient Details tabs. If the patient has preferred pronouns selected in the Patient Details (Office), the pronouns will appear next to their name.
Pronouns can also be added and edited in the Clinical Patient Details screen and the options available can expanded by the practice using list management. Requires Zedmed v36.1.0 or later.
Summary Views
This section can be accessed while in any module and allows you to quickly view a patient's clinical history. There is a tab with information from each module, and right-clicking entries give access to options like view, delete, print and resolve. The Include MHR icon in the Results, Immunisations and Allergies tabs toggles on to show relevant information uploaded by other healthcare providers. The information appears with an Australia icon and you can double-click any record to open it in ZedMed's viewer.
Reference View
This section shows critical information like allergies, recalls and warnings recorded in the patient's file.
History View
Information recorded in the Current Encounter section (using clinical notes and modules) is saved here. The RFE is green, the problem is red, scripts and referrals are blue and each encounter starts with a date, time and duration in bold.
The History View shows when information is added to the patient's My Health Record by other healthcare providers. Select the Include MHR button to toggle this information on and off, and view this information by opening the My Health Record.
History view functionality:
- To add an addendum note to a previous consult, right-click the bold encounter heading and select Add Notes.
- To increase or decrease the level of detail shown, select the 1, 2 and 3 buttons.
- To set how many consultations are shown, select Last 10 , Last 1 Years, 3 Years or All from the Visible field's drop-down.
- To search the history, select the Search History button, enter a search term (like an ailment or drug), and select Find Next. Note: The search only searches the selected history length (the range selected in the Visible field).
- To Reprint a referral request or Rename a referral, right-click the blue referral text and select the appropriate option.
- To Add further notes or Define a problem or RFE, right-click the text (red or green) and select the appropriate option.
- To see what information's been autosaved to the History View from the Current Encounter section, select the refresh icon.
Active encounters
The Current Encounter menu opens when the encounter starts and includes the clinical modules and the RFE entry field. In the screenshot below, you can see the text field where doctors enter consultation notes and the row of modules including Drugs and Referrals. Learn more.
Patient Details tabs
Within Clinical Records, is a Patient Details section that doctors can use to record personnel information. There are 6 tabs used to separate the types of information as explained below.
To open Patient Details, select the spanner icon in the Patient Demographics section.
Patient Details
This tab contains the information in the patient's record in Zedmed Office. Any updates made in Office are reflected in this tab.
NOK and Emergency Contact
Any details entered here will also be visible through the Patient Details Screen.
Family, Social & Past History
This tab has a selection of text fields for recording key personal information including the patient's Marital Status, Sexuality, Family History and Social History. If the patient has preferred pronouns, this information should be recorded in the Alerts section of the Patient Record in Office.
In Zedmed v36.3.3 and later, you can add the patient's ethnicity from the list of options provided. Select Set to open the Select Ethnicity screen, tick the applicable box from the list provided and select Close to save the selection.
Smoking
Details of the patient's smoking status can be recorded here.
Alcohol
The Alcohol Audit Questionnaire has been created by the World Health Organisation. If the full questionnaire is completed, it will generate an audit score indicating whether the patient has hazardous alcohol use or dependency. You can also choose to only complete the first few questions to have some basic drinking information merged into documents.
Other Clinicians
This tab is used to link other practitioners involved in the patient's care. Select the magnifying glass next to the relevant field to search the address book and select the appropriate addressee. Multiple other clinicians can be recorded for each patient.
Linked practitioners can make entries in the record and are the default recipients for letters. For example, a specialist could add a patient's General Practitioner so that when they write a letter, it will default to that GP and add Other Clinicians to the Cc: list.
