Patient Observations
Record important medical observations, history, and pre-operative notes for each patient.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
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
Observation Types
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
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
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