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Viewing and updating entries in the patient data section
Viewing and updating entries in the patient data section

How to navigate patient data in the patient's chart.

Updated over 3 months ago

Patient data is core information about a patient. For example, their demographics (name, date of birth, etc.).

You can view, add, and update this data in multiple areas of the patient chart. It is used to drive efficiency, help with clinical workflows and support high-quality data reporting. The areas in the CHR where you can interact with patient data include the patient data section of both summary and dashboard views, the patient header, forms, encounter templates, Qnaires, flowsheets, analytics, letters, and referrals.

Patient data is organized into categories, each with its own properties. The TELUS Collaborative Health Record (CHR) has three default patient data categories: Demographics, Social History and Vitals. Your CHR may also have additional patient data categories, for example, Preventive Care and Rourke.

In the Patient Data section of the patient's chart, each patient data category has its own folder, and within each folder, there are related patient data properties. For example, in the Vitals folder, there is Blood Pressure and BMI. Beside each patient data property, the most recent value appears. A data property with no value shows blank or No Entry. You can view additional data properties in the data entry window. For example, click any value in Vitals to see the additional data properties of Systolic, Diastolic, or if All Records is not selected, a data property that does not have a value.

πŸ’‘ Tip: In the Summary view, you can decide if you want to see patient data categories and data properties with no entries. Click the gear icon and select All Records.

Steps

  1. Open the Patient Data section of the chart from the Summary view or from Start/Open > Patient Data.

  2. Each patient data category has its own folder. For example, Demographics or Vitals. Click a folder to open it and view the patient data properties.

    πŸ’‘ Tip: If you always use a patient data category, you can have it open by default. In the Patient Data section, click Auto Expand. Or, in the Summary view, click the + icon.

  3. The following actions are available for each data property:

Actions

Description

Adding or updating patient data values

To add or update a value:

  1. Click No Entry or the current value. A new data entry window appears.

  2. Click the empty field. Depending on the data type, type text or choose from a list.

    πŸ“Œ Note: The value of the last entry with the date it was entered appears beside the empty field.

  3. Click Save.

πŸ’‘ Tip: To change what units (Metric or Imperial) you want to record and view patient measurements in, refer to Modifying your user preferences.

Graphing patient data values

If the data property can be graphed, click the name to open a graph. For example, Blood Pressure. If you click a data property that you cannot graph, the data entry window opens.

πŸ’‘ Tip: To trend a data property that you cannot graph, click the clock icon beside it to view its history

Managing alerts

Create customized alerts based on a reference range or an expiry date. For example, you can flag an overdue blood pressure check for a hypertensive patient. For more information, refer to Configuring flowsheet and patient data alerts.

If a data property alert is triggered, the corresponding alert colour and description appears.

πŸ’‘ Tip: Province-specific alerts are pre-configured in some specialized data categories, such as Preventive Care.

Viewing the history of patient data

Click the clock icon beside the patient data property to view a historical record of all previously recorded values.

The History window opens. Each update has a column that identifies the value entered, as well as the user who entered it and when. For vitals added in an encounter note, the date shown is the date from the Time field in the vitals section of the encounter (i.e. If you back-dated the vital to a previous date, that date is shown instead of the date you entered it). This is helpful when adding historical records.

πŸ“Œ Note: If a patient data entry is made in error, for example a typo or entered on the wrong patient chart, you can delete the incorrect value. For more information, refer to Deleting patient data entries.

πŸ’‘ Tip: To show the date the patient data values were last updated, in the Patient Data section, click Dates and times. This shows the date and time in the Summary view as well.

πŸ“Œ Note: For vitals added in an encounter note, the date shown is the date from the Time field in the vitals section of the encounter.

Updated August 28, 2024

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