Clinical Information (Web App)

The main purpose of the Doctor Note Form is to document an entry into a medical or health record made by a physician, nurse, lab technician or any other member of a patient's healthcare team. Accurate and complete medical notes ensure systematic documentation of a patient's medical history, diagnosis, treatment and care.

From the Diary click on Clinical >> Doctor Note

• History: The medical history of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information, with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient.
• Examination: In a physical examination, medical examination, or clinical examination, a medical practitioner examines the patient for any possible medical signs or symptoms of a medical condition.
• Diagnosis: Medical diagnosis is the process of determining which disease or condition explains the patient's symptoms and signs.
• Treatment: is the attempted remediation of a health problem, usually following a diagnosis. As a rule, each treatment has indications and contraindications.
• Plan: A treatment plan is a detailed plan tailored to the individual patient and is a powerful tool for engaging the patient in their treatment. 
• Nurse Instruction: refers to the use of nursing staff teaching skills to provide patients with planned learning methods, and to subsequently expand patients' health knowledge and influence their self-care behaviour.

TAKE NOTE: Most of the fields is FREE TEXT fields. Anything can be typed here and saved.

• History: The medical history of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information, with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient.
• Examination: In a physical examination, medical examination, or clinical examination, a medical practitioner examines the patient for any possible medical signs or symptoms of a medical condition.

• Diagnosis: Medical diagnosis is the process of determining which disease or condition explains the patient's symptoms and signs.
• Treatment: is the attempted remediation of a health problem, usually following a diagnosis. As a rule, each treatment has indications and contraindications.

• Plan: A treatment plan is a detailed plan tailored to the individual patient and is a powerful tool for engaging the patient in their treatment. 
• Nurse Instruction: refers to the use of nursing staff teaching skills to provide patients with planned learning methods, and to subsequently expand patients' health knowledge and influence their self-care behaviour.

• If all the sections are completed it will turn Green with a correction mark in the tick box.
• From here you can Email / Print or Download the Form in CSV or pdf format.