Medical history

A client's medical background is on the Overview tab of their profile. It has three parts:

• Clinical Summary: blood type, allergies and chronic conditions.
• Active Medications: prescriptions that are still active.
• Medical History: a timeline of medical records that staff add by hand, such as visit notes, diagnoses and lab results.

Open a client's Overview tab

1. In the sidebar, go to Clients → Client List.
2. Click the client.
3. The profile opens on the Overview tab. If another tab is open, click Overview.

From top to bottom, the tab shows:

• An Allergy Alert banner, if the client has allergies recorded. It lists every allergy.
• Vitals: the client's vital signs.
• Clinical Summary: Blood Type, Chronic Conditions and Allergies. If no allergies were entered, Allergies shows Not recorded. This does not mean the client has no allergies. It means nobody recorded them.
• Active Medications: up to five active or draft prescriptions, with dose, frequency and date. If there are none, it shows No active medications recorded.
• Medical History: the timeline of records, grouped by month, newest first.

Update allergies, chronic conditions and blood type

These fields are part of the client's record, not of the timeline. You change them in the client form.

1. On the client's profile, click Edit.
2. In the step bar, click Clinical.
3. Change Blood Type, Allergies or Chronic Conditions:
   • To add an allergy or condition, open the field and pick it from the list. If it is not in the list, type it and click Add "…", or press Enter.
   • To remove one, click the × on its chip.
4. In the step bar, click Review.
5. Click Update Client.

Allergies and chronic conditions are free text. There is no severity, start date or ICD code for them.

Add a medication

The Active Medications list shows the client's prescriptions. You can't add a medication there directly. To add one, prescribe it: click Prescribe at the top of the client's profile. The Prescribe button appears only when the Pharmacy Management module is on and your role can create prescriptions.

Add a medical record

1. On the Overview tab, find Medical History.
2. Click Add Record.
3. In Record Type, choose one of: Visit Note, Diagnosis, Prescription, Lab Result or Clinical Note.
4. Enter a Title.
5. Set the Date of the record.
6. Optional: enter a Description.
7. Optional: turn on Sensitive record (see below).
8. Optional: click Attach files and choose one or more files.
9. Wait until all files finish uploading.
10. Click Save Record.

The record type is a label. A Prescription record does not create a prescription, so it does not appear in Active Medications. Lab Result records also appear on the Labs & Documents tab. See Labs and documents.

Attachments

• Attach files appears only when the File Storage module is on. See Document storage.
• You can attach images, PDF, Word and Excel files, text and CSV files, audio and video.
• Each file can be up to 50 MB.
• Attached files show under the record in the timeline. Click a file to open it in the viewer.

Mark a record as sensitive

Turn on Sensitive record for records such as fertility, psychological or family-planning history.

A sensitive record is visible only to:

• clinic owners and admins, and
• staff whose role has the View sensitive records permission.

Everyone else does not see the record at all. This also applies to the person who created it. If your role doesn't have the permission and you mark a record as sensitive, it disappears from your view when you save. Ask your clinic admin about your role first. See Staff roles.

Sensitive records show a Sensitive badge in the timeline.

Find a record

Above the timeline, use the filters:

• Search records…: searches the title and description.
• Record type: show one or more record types only.
• Date range: All time, Last 30 days or This year.
• Has attachments: show only records with files.

To reset the filters, click Clear filters.

Edit or delete a record

1. Point to the record in the timeline.
2. Click the ⋮ button next to the record's date.
3. Click Edit or Delete.

• Edit opens the record in the same dialog. You can change every field, remove attached files and add new ones. Click Save Record.
• Delete asks for confirmation. Click Delete to confirm. A deleted record leaves the timeline.

Only the person who created the record, or a clinic owner or admin, can edit or delete it. MediSync does not keep a change history for medical records.

Who can do what

Common problems

The Add Record button is greyed out. Your role can't edit clients, or the clinic's subscription is not active. Ask your clinic admin.

"Only the author or an admin can modify this record" You tried to edit or delete a record that someone else created. Ask the author or a clinic admin.

The Attach files button is missing. The File Storage module is off. Ask your clinic admin to turn it on.

A record I saved has disappeared. You probably marked it as sensitive, and your role doesn't have the View sensitive records permission. A clinic admin can still see it.

The Prescribe button is missing. The Pharmacy Management module is off, or your role can't create prescriptions.

Related

• Client notes
• Labs and documents