Medications - current medication Issues including repeat dispensing and medication history
A list of drugs or other forms of medicines that are currently being, or have recently been, used to treat or prevent disease for the patient.
Current repeat medication
A list of repeat drugs or other forms of medicines that are currently being used to treat or prevent disease for the patient. This may also include PRN occasional use medication.
Past medication
A history view of drugs or other forms of medicines that have been used to treat or prevent disease for the patient.
Allergies and adverse reactions
Allergies and adverse reactions – description and date only.
Referrals
Request for transfer of care or requests to provide assessment/treatment or clinical advice on the care of a patient.
Immunisation
Vaccinations and immunisations. May also contain vaccination-related information such as flu vaccine declined.
Uncategorised
Coded record entries not associated with a main clinical area of the record. These are split across three views:
Administrative Items
These include tasks such as scheduling and administering clinical care encounters, clinical communication with other care organisations, administering and monitoring of critical safety processes such as repeat medication administration and call/recall for care. Not all clinical systems support administrative items.
Clinical items
Items of information relating to the care, health, or wellbeing of the patient. Examples of this type of information include screening information and past medical history.
Observations
A clinical observation recorded by health professionals in the course of assessment or care of their patients. Examples include blood pressure measurement, weight, height, or temperature measurement.