How to record patient brief notes using practice management software | Zoho for Healthcare

Record brief notes

Once the patient's vital signs, chief complaint, and medical history have been recorded, the next step is to record their clinical examination, diagnosis/prognosis, investigation request, and result if required.

Record brief notes

1. Open the application and click the Patient tab in the top bar.
2. Select the patient by clicking the Patient ID. You will now be able to view your patient details.
3. Click on the Patient Visit ID
4. Click on the Brief Notes tab, and you will be able to view the details.

Create a new record for clinical examination

1. Enter the details for the following information:
  1. Observation
  2. Observation finding 
  3. Clinical status 


Notes
Click the  to enter additional fields like Clinical Exam Category or Additional Notes. You can also add multiple examination records by clicking on +Add New Record

Create a new record for diagnosis/prognosis

2. Enter the details for the following information:
  1. Diagnosis
  2. Description
  3. Onset date
  4. Severity



Notes
Click the to enter additional fields like Clinical Status, Diagnostic Code, and more. You can also add multiple diagnosis and prognosis records by clicking on +Add New Record


Create a new record for an investigation request

3. Enter the details for the following information:
  1. Service
  2. Priority
  3. Reason
  4. Patient instructions
Notes
Click the to enter additional fields like Service Category, Body and more. You can also add multiple investigation request by clicking on +Add New Record

Create a new record for an investigation results

4. Enter the details for the following information:
  1. Investigation order ID
  2. Upload Files
  3. Service
  4. Note


Notes
Click the to enter additional fields and +Add New Record to record multiple investigation results