Ui

Last updated: 2026-03-29

Overview

The Patient Record (or Master Patient Chart) is the central hub for all patient-related information in the system. It brings together a patient's identity, clinical history, current workflow status (like admissions or appointments), medical orders, and billing into one single, comprehensive view. From here, you can manage every aspect of a patient's journey through the clinic or hospital.

When Do I Use This?

  • Receptionists: When registering a new patient, updating contact details, verifying insurance, or managing appointments.
  • Nurses: When recording triage information, taking vital signs, or updating patient allergies and history.
  • Doctors: During a consultation to review medical history, write clinical notes, or order prescriptions, labs, and radiology.
  • Billing Staff: When processing patient invoices and checking insurance coverages upon discharge.

How To Use

Accessing a Patient Record

  1. Navigate to the Patients list from the main menu.
  2. Use the search bar to find an existing patient by their name or Medical Record Number (MRN).
  3. Click on the patient's name to open their Master Record.
  4. To register a brand-new patient, click + New from the patient list.

Navigating the Chart Sections

Because a patient's medical record holds a lot of information, it is divided into organized tabs or sections. To add information to any specific section (like prescribing a medication or adding a lab request):

  1. Scroll to or click on the relevant section (e.g., Prescriptions).
  2. Click the + Add or New button within that specific section.
  3. Fill out the required information and click Save.

Main Field Descriptions

At the very top of the patient record, you will see the primary identifiers for the patient.

Field Name Description
MRN The Medical Record Number. This is a unique, system-generated ID used to identify the patient. You cannot edit this.
Alert A highly visible text area showing critical warnings (e.g., "Fall Risk" or "Violent Behavior"). This is view-only on the main screen and driven by the Safety section.
Patient Type Categorizes the patient (e.g., Inpatient, Outpatient, VIP). This helps staff quickly identify the service level or status of the patient.

Patient Chart Sections (Tabs)

Below the main patient details, the chart is divided into the following key clinical and administrative areas:

Section Group What You Can Do Here
Critical Safety View and add life-saving alerts, such as severe allergies or critical medical warnings. Always check this first.
Identity & Admin Manage the patient's demographic details (address, contacts) and active Insurance Coverage policies.
Workflow Status Track why the patient is here today. Manage Emergency room visits, Waiting room status, Inpatient Admissions, and scheduled Appointments.
Clinical Indicators The core of the medical history. Record Vital Signs, update the active Diagnosis/Problem List, review past Medications, Immunizations, Family/Social history, and attach medical Documents.
Orders & Interventions The doctor's plan. Order Prescriptions, Lab Tests, Radiology scans, Surgery, Medical Devices/Implants, or Refer to other specialists.
Specialties Discipline-specific charts. Includes Maternity (Obstetrics/IVF), Pediatrics (Growth charts), Eye/Ear exams (Ophthalmology/Audiology), and comprehensive Dental charting.
Financial View and manage the patient's Billing, invoices, and payment statuses.
Tip: Always verify the patient's Demographics and Insurance Coverage during check-in. Accurate information here prevents billing rejections and ensures you can contact the patient with lab results.
Tip: Sections marked as "Parked" in the system indicate workflows that can be paused or saved as drafts (like building a complex dental treatment plan or compiling a long admission note) before finalizing.
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