Recording a consultation

On a patient's record you record clinical information from dedicated tabs: Vitals, Test results, and Prescriptions, alongside their Profile, Timeline, and shared Files.

Vitals

The Vitals tab lets you record structured measurements taken during or after a visit — weight, height, blood pressure (systolic and diastolic together), heart rate, body temperature, oxygen saturation, respiratory rate. Every field is optional; fill in the ones you took, set when they were taken, and save.

What happens on save:

• The readings land as structured values, chartable on the patient's Health trends view.
• Each value is checked against age- and sex-aware reference ranges (and, for children, WHO/CDC growth percentiles) and flagged if out of range.
• A grouped entry appears on the patient's medical timeline.

A reading you record is part of the clinical record — the patient can see it but not edit or delete it. To correct one, record a new reading.

Notes

Consultation notes and diagnoses attached to an appointment become part of the patient's timeline according to the access model — the patient sees their own record in full; other doctors see your entries per their own grant.

Ordering exams and prescribing

• Test results tab — order an exam from the canonical test catalogue with a note, then record the result when it comes back. See Test results and trends.
• Prescriptions tab — issue a prescription with per-drug instructions. See Prescriptions.

What the patient sees

Everything you record on a patient's record is visible to that patient — they own it. Business staff at your clinic do not see clinical content just by being staff; that always requires the treating doctor's own access grant.