Vitals & Clinical Notes

Introduction

The Encounter tab on a patient’s chart is the running clinical narrative for the current visit — vital sign readings taken over time, plus notes written by doctors and nurses as the encounter progresses.

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Key Concepts

Vitals vs. Doctor Notes vs. Nurse Notes

These are three distinct record types, each with its own permission set — a nurse’s ability to record vitals doesn’t automatically grant access to write a doctor’s note, and vice versa:

Record type	Who typically records it	Permission resource
Vital signs	Nurses	vitals
Doctor notes	Physicians	doctor notes
Nurse notes	Nurses	nurse notes

All three follow the same void-not-delete pattern: an incorrect entry is never removed from the record, only marked voided with a reason. This preserves a complete, tamper-evident audit trail — voided entries stay visible (struck through or grayed out) rather than disappearing.

Normal Ranges and Out-of-Range Highlighting

Vitals outside the expected adult range are highlighted in amber and bolded so an abnormal reading is impossible to miss on the chart:

Vital	Normal range
Blood pressure (systolic)	90–140 mmHg
Blood pressure (diastolic)	60–90 mmHg
Heart rate	60–100 bpm
Respiratory rate	12–20 breaths/min
Temperature	36.1–37.2 °C
Oxygen saturation	95–100%

Height, weight, and pain score have no highlighted range — they’re recorded but not flagged.

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Use Cases

Recording New Vitals

Vitals are captured during the intake wizard when an encounter opens, and again at any point during the encounter:

1. Open the encounter and go to the Encounter tab.
2. Click Add Vitals.
3. Enter the readings you have — blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, pain score, height, and weight. Not all fields are required every time.
4. Click Save.

The new reading appears at the top of the vitals table, timestamped and attributed to the staff member who recorded it.

Voiding an Incorrect Vitals Entry

1. Find the incorrect reading in the vitals table.
2. Click Void.
3. Choose a reason: Duplicate entry, Incorrect values, Wrong patient, Equipment error, or Others (specify).
4. Confirm.

The entry remains in the table, marked as voided, rather than disappearing.

Adding a Doctor’s Note

1. Open the encounter and go to the Encounter tab.
2. Click Add Note under the Doctor Notes section.
3. Write the note content.
4. Click Save.

The note is timestamped and attributed to the physician who wrote it.

Adding a Nurse’s Note

Follow the same steps as a doctor’s note, under the Nurse Notes section. Nurse and doctor notes are tracked separately even though they appear on the same tab.

Voiding a Clinical Note

Click Void on the note, choose a reason (the same list used for vitals), and confirm. Only staff holding the void permission for that specific note type (doctor or nurse) can void it — a nurse cannot void a doctor’s note, and vice versa.

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Reference

Permissions

Resource	Actions
vitals	view, create, void
doctor notes	view, create, void
nurse notes	view, create, void