How to manage Clinical Records

The Clinical Records tab lets you view, enter, and manage structured test or procedure records for a patient. This article covers navigation, comparisons, attachments, workflow management, and flags.

The Clinical Records tab

The tab is divided into a navigation tree on the left and a record display area on the right.

The navigation tree contains:

• Group headers (e.g. Invasive, Hepatology, Respiratory etc.)
• Clinical Records (e.g. Echocardiogram, Holter, ABP Protocols etc.)
• Individual patient records listed under each header, showing the date

Action buttons

The following buttons appear at the top of the record display area:

Compare measurements over time

Use the Compare function to track how a specific measurement has changed across multiple records.

1. In the navigation tree, select the test or procedure group you want to compare.
2. Click the Compare button in the bottom right of the screen.
3. The display area changes to a grid. Each record is shown as a row; each measurement appears as a column.
4. Scroll right to view all measurement columns.
5. Click Compare again to return to the standard record view.

Compare is not the record's history. Compare lines up the same measurements from different records of the same test type, so you can see change over time. To see when a single record was created or last modified, use the History button on the Info screen instead (see Review record information below).

Manage attachments

Use the Attachments tab within a clinical record to attach images or documents.

Attachments can be classified as:

• Primary Distribution - distributed as the clinical record (e.g. an external echocardiogram report)
• Embed in Report - image is embedded in the report when distributed
• Attachments - Distribution - attached alongside the clinical report
• Attachments - Internal - attached to the record but not distributed externally

Import a new file

Use any of the following methods to add a new external file:

Import New button

1. Click Import New.
2. The Import Documents & Images screen opens. Follow the on-screen prompts to classify and import the file.

Quick Paste icon

1. Copy the file to your clipboard.
2. Click the Quick Paste icon in the attachments toolbar.
3. The file imports with the caption "Imported document".
4. To update the caption, double-click the file entry and enter the required text.

Drag and drop

1. Select one or more files in Windows Explorer.
2. Drag the files onto the attachments panel. The Import Documents & Images screen opens showing the selected files.
3. Click Import. The Classify Documents screen opens.
4. Update the classification details as needed.
5. Click OK to complete the import.

Attach an existing file

1. Click Attach Existing.
2. In the Attach Existing Document screen, select the folder from the Category drop-down.
3. The folder contents appear in the Documents field.
4. Select the file to preview it, then click Attach to confirm.

In multi-file views, a Position column appears in the file list. Right-click an attachment to reassign its position. Select the Lock Visible Documents checkbox to keep the current selection fixed.

Drag and drop files in the list to change the order they appear when included in a report.

Review record information

Click the Info button to open the Clinical Record Information screen. This screen is divided into five colour-coded panels.

Manage workflow status

The Status field in the Workflow and Distribution panel controls where the record sits in the Document Workflow system.

If a record won't set to Final

A record that refuses to finalise is almost always blocked by one of the following:

1. Validation on the record type. Some record types require certain fields to be complete and valid before the record can be finalised. If validation fails, the record stays unfinalised. Complete the missing or invalid fields, then set the status again.
2. The Attention Required flag is set. A flagged record cannot be set to Final until the flag is removed (see Flag a record for attention below).
3. Permissions. Finalising can be restricted to a permission group per record type. If you cannot finalise a record type that colleagues can, ask your system administrator to check your permissions.

Flag a record for attention

The Attention Required flag alerts the Reporting Doctor to review a note before setting the record to Final. A record flagged as Attention Required cannot be set to Final until the flag is removed.

Records flagged with Attention Required are highlighted in red in the Document Management screen.

Set the flag from a Clinical Record

1. Open the clinical record.
2. Click Note.
3. In the Modify Note window, select the Attention Required checkbox.
4. Enter the note text.
5. Click OK.

Set the flag from Document Management

1. In the Document Management screen, click the note icon in the Note column for the record.
2. Select the Attention Required checkbox, enter a note, and click OK.

Remove the flag

1. Open the Note for the flagged record (via Clinical Records or Document Management).
2. Clear the Attention Required checkbox.
3. Click OK.
4. The record can now be set to Final.

Shortcut keys

Select Alt - if a button or menu item now has an underlined character, press Alt + that character to activate it.