A draft Treatment Record opens when the Patient is checked in, and its author opens it with Start, then Open record. Each step saves as you go. See An Appointment, from Booking to Checkout for the Booking around it.
Hand the device to the Patient
A form the Patient answers themselves is theirs to answer on your device. Its button names the Patient: your device then shows only that form until you choose Staff, type your Signing PIN and choose Take back, which returns you to the step. This covers a Consent to sign, an Acknowledgement, the question about recording the consultation and Marketing Consent. For a Patient who cannot sign, Can't sign themselves? Sign on their behalf stays on your screen.
The steps
If your Clinic uses the notetaker, the record first asks to record: hand the device over for the Patient to agree, then Start recording, or Not today.
- Medical History: Confirm unchanged, or Something has changed to save a new version. Any Consent signed against the old version must then be signed again.
- Confirm consent: you confirm each Consent in the room at every Appointment with Confirm as and your name. The Patient signs a missing or out-of-date one on your device.
- Clinical Flags warn only: pick a reason and Acknowledge each.
- Before photos, Stock Items and Opening, Injection Map and Marketing Consent follow the Treatment Type.
- Notes and sketches: each section saves when you leave it, and Go to the sign screen waits until it has.
For a prescription-only Treatment Type, A Prescription comes first: a prescriber assesses the Patient in person and signs a Prescription naming one administrator before anyone treats.
Sketches
To show the Patient what you discussed, choose New sketch in Notes and sketches, pick what to Draw on (a face outline from the front, at 45° or in profile, each drawn Female or Male, or the lips close up; a body outline from the front, the back or with the arms raised; one of today's before or after photos; or a blank page), draw with a pencil or a finger and choose Save sketch. While the record is a draft you can Redraw or Remove one. Sketches from earlier visits show under From earlier visits. A sketch is part of the record, never a record of doses, and never reaches the Patient Portal.
Sign the record
The sign screen lists the Record Requirements Clayform sets for the Treatment Type, with Go to step beside anything outstanding, such as a Consent not yet signed or confirmed. Check the Return Visit, enter your Signing PIN and choose Sign record.
Only the author signs, while their Verification is current. Signing locks the record and, when the Treatment Type has an Aftercare Template, issues the Aftercare. A later change is an Amendment: Add an Amendment with a reason, and Add a sketch adds a sketch the same way.