Medical Records

Medical Records holds the visit notes for each client. Templates enforce structure — chief complaint, examination, assessment, plan. Vitals are captured per visit and trended across history. If AI Assistant is on, the add-on suggests a diagnosis based on chief complaint and examination.

1. 1Dashboard → Add-ons → Medical Records → Activate.
2. 2Build at least one template before writing records — the structure pays off fast.

Templates are the skeleton of a record — which sections appear, which vitals are mandatory. Medical Records → Templates → Add Template.

• Name the template ("General Checkup", "Post-op Follow-up").
• Enable the sections you want: Chief Complaint, Examination, Assessment, Plan, custom sections.
• Mark which vitals are required — BP, HR, temperature, weight, height.
• Save. The template shows up in the record-creation dropdown.

1. 1Medical Records → Create.
2. 2Pick the client and, optionally, a template — required fields pre-appear.
3. 3Fill in the sections and the vitals block.
4. 4Add a diagnosis (free-text) and an ICD-10 code if you use them.
5. 5Set a follow-up date if the visit needs one.
6. 6Save as Draft while you iterate, or Finalise to lock and print.

Each finalised record contributes a vitals snapshot. The client profile has a Vital Trends chart — BP, HR, temperature, weight — across every visit. Useful for chronic-condition monitoring or just a weight-loss journey.

If the AI Assistant add-on is on, Draft records get a Suggest Diagnosis button. The AI reads the chief complaint and examination and returns a ranked list of likely diagnoses with reasoning — meant as a safety net, not a replacement for the clinician's judgement.

Only finalised records are printable. The PDF shows patient info, all sections, the vitals snapshot, and the ICD-10 code if present. Finalised records are also visible on the client portal.

• Build templates for your top three visit types. They'll cover 80 percent of your records.
• Record vitals even when they feel unnecessary — they're the backbone of the trend chart.
• Use the AI diagnosis as a checklist, not an oracle. Treat it like a second opinion from a junior.