Clinical History

A patient’s clinical history covers three kinds of record:

• Allergies: drug, food, environmental or other. Each has a severity (mild, moderate, severe or life-threatening), the reaction, and the date it started.
• Chronic Diagnoses: long-term conditions from the disease catalog, with the date of diagnosis.
• Surgical History: past surgeries, with the date and hospital.

The patient’s family history sits beside them; unlike these three, only the patient records it.

Each appears as a card in the right-hand panel of the visit page. A card shows a compact list; Expand opens the full table.

Who recorded it

Every entry is one of two kinds:

• Professional: recorded by your staff. It is stamped with the staff member and your organization, and with the visit if it was recorded during one.
• Self-Reported: recorded by the patient in the patient app.

Each kind can only be edited by whoever created it. Staff can’t change what the patient reported, and the patient can’t change your organization’s records. The item itself (the allergen, disease or surgery) can’t be changed after it is recorded. Delete the entry and add it again instead.

Confirming what the patient reported

When the patient has reported something you have verified, choose Confirm on their entry. This adds a professional copy, linked to the patient’s original. Patients can likewise confirm your records into their own list.

To add a comment as you confirm, choose the comment icon next to Confirm instead. It shows the entry and a box for your comment; choose Accept to confirm with it, or Close to leave without confirming. The comment is yours, on your organization’s copy; the patient’s own note stays on their original. Patients confirming one of your records can likewise add their own note to their copy.

Confirm only works across sides. It appears only on the patient’s self-reported entries, never on your organization’s own records, and each entry can be confirmed once. Confirming an entry your organization already confirmed shows an error and adds nothing, even if two people confirm it at the same moment. For chronic diagnoses, the same happens when your organization already has its own record of that disease.

You only see what a patient reported once they have fully accepted your organization. You never see other organizations’ records.

One row per item

In your lists, each allergen, disease or surgery name appears once, even when both you and the patient recorded it. When both exist, the list shows your organization’s record. Deleted entries never appear.

Once an entry is deleted, the same allergy, disease or surgery can be recorded again.

Allergies

Choose Add on the Allergies card to record one. The type (drug, food, environmental or other) and the allergen are required. Severity, the date it started, the reaction and a comment are optional. The allergy is recorded as part of the visit you are in, so you can add allergies only while the visit is open.

Recording an allergen that is already on the list adds a second entry rather than showing an error. Your list still shows that allergen once. In the full table, Delete appears only on your organization’s entries: only the patient can delete what they reported. The comment column shows your staff’s comment and, labelled, the patient’s note.

Notes

Each entry can carry two notes: the patient’s own note, which only the patient writes, and a staff comment, which only your staff write. Neither side can change the other’s note.

Chronic diagnoses

Choose Add on the Diagnosis card to record one. Search for the disease by name. Type at least two letters: two or three find names in your language with a word that starts with them, four or more find them anywhere in a name, in any language. The best matches come first. Results show the ICD-10 code and name, and only chronic, long-term conditions are offered. Short-lived conditions are recorded as visit diagnoses instead.

Pick the disease and the date of diagnosis; a comment is optional. The diagnosis is recorded as part of the visit you are in, so you can add diagnoses only while the visit is open. Your organization can hold one record of each disease per patient: adding it again shows an error until the first one is deleted.

In the full table, Delete appears only on your organization’s diagnoses: only the patient can delete what they reported. The comment column shows your staff’s comment and, labelled, the patient’s note.

Surgical history

Choose Add Surgery (the + on the Surgical History card) to record a past surgery. The surgery name is required. The date, the hospital and a comment are optional. The surgery is recorded as part of the visit you are in, so you can add surgeries only while the visit is open.

Recording a surgery that is already on the list adds a second entry rather than showing an error. Your list still shows each surgery name once, so two separate operations with the same name also appear as one row. In the full table, Delete appears only on your organization’s entries: only the patient can delete what they reported. The comment column shows your staff’s comment and, labelled, the patient’s note.

Who sees what

Viewing each kind of record, and adding or changing it, needs the matching permission: for allergies, for diagnoses and for surgical history. Patients always see all of their own records, from every organization.

Family history

The patient’s family history lists diseases their relatives have been diagnosed with: which relative (father, mother, a sibling, several siblings, a child, several children or another relative), the disease, and the relative’s age at diagnosis when the patient knows it. It is the patient’s own account: the patient adds and removes entries in the patient app, or reports them on a pre-visit intake form. Your staff read it, with the permission to view family history, in the Family History section of a visit’s right panel; expand it to see each entry’s ICD-10 code. Staff cannot add, change or remove entries.