Update Clinical Records
Add a problem to a patient chart.
Update clinical records by adding a problem directly to the patient's chart.
Who does this: Providers and clinic administrators.
Steps
Open Patients from the main menu.
Find the patient and open the chart.
Open Problems.
Select Add problem.
Enter the Problem in Add problem.
Add an Onset date if known.
Choose Status as Active or Inactive.
Select Add problem.
The problem appears in the patient chart.
Common pitfall: Only add information you have verified in the patient's clinical record.
Troubleshooting
The Add problem button is missing. Ask an administrator to confirm your chart access.
The problem appears in the wrong status. Open the problem workflow again and check Status before saving.
Related
- Before this: Open Patient Charts
- After this: Start a New Encounter
- Instead: Review Chart Notes
Need help? Contact your administrator or reach out to support.