Clinical
Records & Scripts
The Clinical Records module captures every detail of a patient's medical encounter—history, vitals, diagnosis, treatment plan, prescriptions, and follow-up instructions. It creates a permanent digital record that follows the patient throughout their care journey.
What are Clinical Records?
Clinical Records is where doctors document everything about a patient visit. It includes medical history (past illnesses, surgeries, allergies),vital signs (BP, heart rate, temperature, SpO2), physical examination findings, diagnosis (the doctor's conclusion),treatment plans, prescriptions (medications with dosage and instructions), and follow-up recommendations.
Prescriptions can be printed (for patients who prefer paper) or sent digitally to the pharmacy. Medications can be discontinued with a reason, creating a complete medication history.
Why Does It Exist?
- → Illegible handwriting — Handwritten notes and prescriptions cause medical errors
- → Lost information — Paper records get lost. Digital records are permanent
- → Medication errors — Without structured prescriptions, wrong doses or drug interactions can occur
- → Continuity of care — The next doctor needs to know what the previous doctor found and prescribed
How Clinical Records Work
History & Vitals
The doctor or nurse reviews the patient's medical history (past visits, allergies, chronic conditions) from the clinical timeline. Current vitals (BP, pulse, temp, SpO2, weight) are recorded. The patient's chief complaint and history of present illness are noted.
Examination & Diagnosis
The doctor records physical examination findings (organized by body system). Based on the findings and history, the doctor enters a diagnosis. The system can suggest common diagnoses based on symptoms and can link to ICD-10 codes for billing.
Prescriptions
The doctor prescribes medications: select medicine from formulary, specify dose, frequency, route, duration, and any special instructions. The prescription is digitally signed. It appears instantly in the pharmacy system. The patient can receive a printed or digital copy.
Follow-up & Completion
The doctor sets follow-up instructions: when to return, what to watch for, and which tests to get before the next visit. The clinical record is finalized and added to the patient's timeline. It's now available for future reference by any authorized provider.
Every Feature Explained
Structured Vitals Recording
Record vitals (BP, HR, Temp, SpO2, RR) in structured fields.
Enables trend analysis and automatic flagging of abnormal values.
Each vital is a separate field with normal ranges. Abnormal values are highlighted. Previous readings are shown for comparison. Trends are charted over time.
Digital Prescriptions
Electronic prescriptions with full medication details.
Eliminates handwriting errors. Pharmacy gets the prescription instantly.
Doctor selects medicine, dose, frequency, route, duration. The system checks for allergies and interactions. Prescription is signed digitally and sent to pharmacy.
Medication Discontinuation
Stop a medication with a documented reason.
When a medication is no longer needed or causing side effects, it should be formally discontinued.
Doctor selects the active prescription and enters a discontinuation reason. The medication is marked as discontinued on the patient's active medications list.
Printable Prescription Output
Generate a clean, print-friendly prescription sheet.
Some patients prefer paper prescriptions for their own records or for other pharmacies.
Generates a formatted PDF with doctor's letterhead, patient info, medications list, dosage instructions, and doctor's signature.
Clinical Timeline Integration
Records are automatically added to the patient's clinical timeline.
Future providers can see the complete history in chronological order.
When a clinical record is finalized, it appears on the patient's timeline alongside lab results, imaging reports, and visit summaries.
Technical Architecture
| Field | Type | Institutional Role |
|---|---|---|
| id | UUID | Unique identifier for the clinical record. |
| patientId | UUID | The patient this record belongs to. |
| doctorId | UUID | The doctor who created the record. |
| diagnosis | Text | The doctor's diagnosis and clinical impression. |
| vitals | JSONB | Structured snapshot of BP, HR, Temp, SpO2, RR at the time of visit. |
Note: Sensitive fields use AES-256 field-level encryption where applicable.
Governance & Power
clinical:editclinical:viewpharmacy:viewAppend-Only Records
Clinical records are immutable once finalized. Corrections create amendments with a visible audit trail. Nothing is permanently deleted.
Sign & Amend (roadmap)
Permissions clinical:sign and clinical:amend are reserved for a future attestation workflow (electronic sign-off and post-sign amendments). Today, edits use clinical:edit; consents already support signing via consents:sign.
Drug Interaction Check
When prescribing, the system checks the patient's active medication list for potential interactions and displays warnings before finalizing.
Allergy Flagging
Known allergies are displayed prominently during prescription. Prescribing a known allergen shows a blocking warning.