One patient's longitudinal record: their problems, allergies, medicines, immunisations, vital signs and observations, history, care plans and care team, the documents held for them, and how they are identified. The chart opens inside a patient workspace, so it always has a patient in front of it, and it opens on a summary of what changes what you do next.
There is no list of charts to pick from. You open a patient, using Open a patient in the sidebar or from a worklist row, and their record opens in their workspace. The sidebar then shows whose workspaces you have open, the border around the screen tells you at a glance that you are inside one patient's record, and the word PATIENT and their name stay in the green strip at the top of the screen while you work.
Application view at the top of the sidebar takes you back to worklists and administration without closing anybody. While a patient is still open, the sidebar offers View patient with their name and record number: select it to return to their record, on the screen and section you left, without searching for them again. With more than one patient open, View patient lists every one of them with their record number and marks the current one; choose whose record to go back to. If their workspace closed while you were away, or another window moved you to a different patient, View patient tells you and opens nobody in their place.
A patient belongs to the clinic or hospital you opened them in, so the workspace switcher in the top bar is locked while you are in their record: it shows a padlock and says why. Select Application view first, then switch. The patients you had open are not closed by leaving their record.
You can have up to five patients open and move between them in the sidebar. Each one shows the name and the record number, because two patients with the same surname is ordinary. Opening a sixth asks you to close one by name first: nothing is ever closed for you, because the one you would lose is usually the one you were still writing in.
Open patients close when you sign out, and after thirty minutes without use. A shared computer on the ward never carries the last person's patients into your shift, and a workspace left open at lunch is gone when you come back rather than waiting there with somebody's record on screen.
The banner sits under the page title and never scrolls away. It shows the patient's name, their age and sex, their record number, date of birth and the end of their mobile number, so you can confirm whose record you are looking at before acting on anything in it. If you correct patients' details, what the banner says is also the way to fix it: Date of birth not recorded, Sex not recorded, a recorded date of birth and the age tag open a short form on that field, No record number issued issues the number, and the mobile number opens Profile and contact. Beside them is a strip of alerts: allergies and active problems from the chart, and a provisional or restricted identity. When the chart holds no allergy at all the strip says None recorded, which is not the same as no known allergies. When the patient is staying with you, the stay is shown on the right. The line underneath says when the chart on screen was read, which role you are reading it as, and that your access is logged. If the banner reads Identity not loaded, the patient could not be named: nothing about them has been checked, so the buttons that record on the chart wait until you try again and they are named.
If this record was merged into another, the chart says so and links to the surviving record, where its entries, identifiers and history now are. Nothing can be recorded on the merged record itself.
A patient registered at the desk starts as provisional, and the banner flags it. Registration establishes a mobile number, not proof of which person is standing there. Confirm identity in the way your clinic requires before acting on the chart.
While a patient is open, the sections of their record are the sidebar: Summary, Problems, Allergies, Medications and the rest, one press each, so the chart itself uses the full width of the screen. On a phone, where there is no sidebar, they are the row above the section. Problems, allergies, medications, immunisations and history show a count of what is in force beside them. A count with a plus sign means there are older entries still to read, and Show older reads them.
Correct the patient's name, date of birth, administrative sex and email address in one place, and change their mobile number, which moves them to the household at the new number. Only what you change is saved, against the version you opened, so a colleague's correction a moment earlier is never overwritten: your save is refused and theirs is shown. The same profile opens from the Patients list.
Every message the clinic sent this patient on WhatsApp, and every reply the patient sent back, in one conversation, oldest at the top and newest at the bottom. The clinic's messages are on the right, marked with the reminder or notice they were and the clinic number they went from; messages somebody typed on the clinic's phone are marked as such. The patient's replies are on the left. Ticks show whether a message was sent, delivered or read, and a message that could not be delivered says so. Doctors, nurses, care coordinators and administrators who may change the chart can answer from here: the reply goes out from the clinic number the conversation is on, and it is signed with your name in the conversation. WhatsApp is not a secure clinical channel, so a reply that names results, diagnoses, medicines or other clinical details is refused. A photo, voice note, video or document the patient sent opens with Open on its bubble when the file was kept; a file that was too large, of a type that is not kept, or that could not be downloaded says why. Files from WhatsApp are not checked for viruses.
A WhatsApp conversation is with a phone number, and a family often shares one. A reply is filed against the patient the message it quoted was about; otherwise the one patient the clinic's recent messages on that number were about; otherwise the only patient registered with that number; otherwise, for a shared family number, the family's main member. A reply filed by a quote, by the last message or to the family's main member says so under it, so you can tell a reply that answered this patient's reminder from one that simply came from a number the family shares. A reply from a number several people share that none of these settles, including one sent when the clinic had recently written about two members of the family, is not filed against anybody rather than against the wrong person: it waits in WhatsApp to file, where a member of staff reads it and files it to the right patient, and it is then marked as filed by staff.
A reply that is only an opt-out word, such as STOP, is marked in the conversation, and the section says when the patient last sent one. It does not unsubscribe them by itself, because a patient answering a reminder with Cancel usually means the appointment. Check what they meant and, if they want no more messages, record the opt-out on their contact record in Contacts.
Verify by WhatsApp sends a six-digit code to the mobile number, and Verify by email sends one to the email address. Ask the patient for the code and enter it: it lasts ten minutes, five wrong codes end it, and a new code can be sent after a minute, up to five an hour. Each is verified separately, and changing the number or the address makes it unverified again. Codes are never shown to staff or kept, and a verified number proves the patient can receive messages there, not who they are.
Every patient is given a record number by the system when they are registered: digits only, unique in this workspace, never reused and never typed by anybody. The last digit is a check digit, so a mistyped number is not found as somebody else. A patient registered before numbers were issued reads No record number issued; for somebody who corrects patient details those words issue it, and pressing them twice still gives one number.
Six cards: allergies, active problems, the latest observations, results, current medications and what is coming up. Every row carries a mark and a word as well as a colour, so nothing is read by colour alone. Readings are shown as they were recorded: nothing on the summary is compared with a reference range, and each card ends with a line saying what it does not check. A card whose part of the chart could not be read says so on a row of its own rather than looking empty. Select a card's title to open its section.
Shows the patient's name, date of birth, administrative sex and mobile, and their medical record numbers and other identifiers. Edit identity and identifiers opens them for changes. One active identifier is the primary one shown in the banner. Saving changes only what you changed, and if somebody else changed the details after you opened them your save is refused and the panel shows theirs, so you can check before saving again.
A chart can be restricted so that being clinical staff here is not enough to open it. A restricted chart is opened by the patient's own account, by a grant recorded in advance, or by an emergency access episode the clinician records for themselves.
Shows whether the chart is restricted, who holds standing access now and until when, and the relationships on file. A relationship says who someone is to the patient; on its own it opens nothing. Manage who can see this chart opens the place to restrict the chart, grant or withdraw access, and record a relationship. Consent to treatment is recorded with the visit or procedure it was given for, not here.
Who opened this chart under emergency access, and standing grants that were withdrawn or ran out. The record of each is kept. Opening a patient is recorded against your name with the basis it was allowed on.
A doctor or nurse who needs a restricted chart can open it by recording why, in their own words. The episode lasts a few hours, is recorded against their name, and is read afterwards. It opens the chart; it does not make the access appropriate.
What this patient is working towards and what is planned to get there. A plan records intent: it does not order, prescribe, refer, book or remind anyone, and marking an activity done records that somebody said it was done. Dated activities and goals still ahead appear under Coming up on the summary.
A goal can be actively worked on and getting worse at the same time, which is the most useful thing a plan can say. Status says whether it is still being pursued; progress says how it is going.
Who is responsible for this patient, and in what capacity, across their stays. Adding someone records responsibility; it does not give them access to the chart.
What this patient is on and what has been given. Each line shows the doses due in the three days either side of now, newest first with a count of the rest; choose Show every dose to read the whole line. Writing a chart line is a doctor's act; a doctor or nurse schedules its doses, choosing the first time, how many and how many hours apart, and sees the times before they are added. Doses are recorded on the drug round, at the bedside, against a list of what is due, rather than from here: giving a dose from a chart opened by name is how the wrong patient's dose gets recorded.
Correcting an entry keeps the previous version and records the reason you give. Marking something as entered in error removes it from the chart and keeps it for the record; it cannot be corrected again afterwards.