Write notes and chart vitals
Add doctor and nursing notes and record a patient's observations during the stay.
The patient chart
Click Open chart on a patient from the ward board or the admissions list. The top of the chart shows who the patient is, their patient number, blood group and emergency contact if known, the bed, doctor, admission time and reason, and in red any Allergies and Long-term conditions.
Under that, four sections are available: Notes, Vitals, Medication and Bill. Adding anything to the chart needs the Hospital Edit permission and works only while the patient is still admitted. After discharge the chart is read-only.
Add a note
- Open the Notes section.
- In Note from, choose Doctor or Nursing.
- Type the note and click Add note.
Each note shows who wrote it, when, and whether it is a doctor or nursing note.
Chart vitals
- Open the Vitals section.
- Fill in whatever you measured: BP top, BP bottom, Pulse, Temp °C, SpO2 % and Breaths/min. You do not need to fill them all, but at least one reading is needed.
- Click Chart vitals.
The readings are listed with the time and who recorded them (Time, BP, Pulse, Temp °C, SpO2 %, Breaths, By). The chart shows the latest 100 readings.
The system checks that the numbers are plausible:
| Reading | Accepted range |
|---|---|
| BP top | 40 to 300 |
| BP bottom | 20 to 200 |
| Pulse | 20 to 300 per minute |
| Temperature | 30 to 45 °C |
| SpO2 | 50 to 100 % |
| Breathing rate | 4 to 80 per minute |
Blood pressure needs both numbers, and the top number must be higher than the bottom one. A reading outside a range is refused with a message, which usually means a typing slip.
Good to know
- Readings are time-stamped when you save them and cannot be dated before the admission or in the future.
- Everyone with Hospital View can read notes and vitals, so grant that permission only to people who should see medical information.