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Patient Observations

Record important medical observations, history, and pre-operative notes for each patient.

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What Are Observations?

Observations capture clinical information about the patient’s condition:
  • Chief Complaint - Primary reason for surgery
  • Injury/Onset Date - When the condition began
  • Medical History - Relevant past conditions
  • Pre-Operative Assessment - Clinical findings before surgery

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Adding an Observation

1

Open Patient Profile

Navigate to the patient’s profile
2

Click Add Observation

Click the observation icon or Add Observation button
3

Enter Details

Complete the observation form:
  • Select observation type
  • Enter date of observation
  • Add clinical notes
4

Save

Click Save to record the observation

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Observation Types

TypeDescription
Chief ComplaintPrimary symptom or reason for visit
Injury DateDate of injury or symptom onset
Medical HistoryRelevant past medical conditions
Physical ExaminationClinical examination findings
Imaging ResultsX-ray, MRI, CT findings
Pre-Op NotesPre-operative assessment notes

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Voice-to-Text

Use voice input to quickly record observations:
1

Click Microphone Icon

Click the microphone button in the text field
2

Speak Your Notes

Dictate your observation clearly
3

Review Transcription

Check the transcribed text for accuracy
4

Edit if Needed

Make any necessary corrections
Voice-to-text supports multiple languages and medical terminology. Speak clearly and at a moderate pace for best results.

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Editing Observations

To modify an existing observation:
1

Open Patient Profile

Navigate to the patient’s observations
2

Select Observation

Click on the observation you want to edit
3

Make Changes

Update the information as needed
4

Save Changes

Click Save to confirm

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Best Practices

  • Record observations as soon as possible for accuracy
  • Use consistent terminology
  • Include relevant dates and measurements
  • Reference imaging studies by date and type