Purpose
When recording observations there's a standard list that will often be recorded in one encounter, Medicus provides a template where some or all of these observations can be recorded and coded. This user guide shows you how to use the Routine Observations action to record these from the patient's care record.
Navigating to the care record
There are two ways to navigate to the patient record within Medicus:
- Using the patient finder.
- By selecting a patient from the patient list, located in the Patient Administration module.
Once you select the patient you'd like to view through one of the methods outlined above, you'll be taken to the clinical care record.
Accessing the routine observations form
To access the Routine Observations from the Patient's care record click Actions then Routine Observations.
To record Routine Observations from within a consultation type /Routine in the Observations box and click Routine Observations.
Recording Routine Observations
The Routine Observations are split into two sections, Breathing & Circulation and Measurements.
Under Breathing & Circulation you can record Oxygen saturation, Respiratory rate, Blood pressure, Heart rate and Temperature. If there is a previous reading available, this will be shown next to the text box with the date.
Under the Measurements section you can record the patient's weight and if you select Calculate BMI you will also be prompted to enter the patient's height.
If an observation is inputted which is considered as too high, a warning will be displayed so that the input can be corrected.
You can record some or all of the observations. The only fields required are the date, organisation and name of the person recording the observations.
Once you save the observations they will be added to your consultation notes, or saved to the Journal as Recorded Observations.