mediSIGHT – Creating an Encounter: Note

DRAFT

It can be necessary to record information in the patient record even when a formal clinical encounter has not occurred.  This is usually best done in “Note”.

• Open mediSIGHT and find the patient record
• Click “Create new +” and choose Note
• Choose the correct Pathway
• Select an Activity (the most common are listed below)
  • Discussion
  • Email received / sent
  • Letter received / sent
  • Management plan
  • Phone call made to GP / patient / relative
  • Phone call received
  • Reporting results
• Enter the documentation under the Plan > Comments section.
  Do not use the Notes section because the information saved here is not readily viewable on the overview screen.

• Add other plans outcomes including Medication, Procedures, Further visits and Discharge as necessary
• A letter will currently not be generated, although the tickbox is ticked.  See “Letter Creation” for more detail.