Medical notes - VeriPath

A consultation ends and the record of it is whatever the clinician wrote down. The app attaches that note onto the appointment itself and codes the diagnosis as the note is saved, so the record is finished when the consultation is — rather than pieced together from memory at the end of the day.

VeriPath Health Clinics — the clinical note form: the diagnosis searched and coded with its site, side and severity in place above the clinician's narrative, with the Save Coded Note button below

One note, written against the visit

The note is opened from the appointment and stays with it: the patient, the date, the clinician who wrote it. Nothing to file afterwards, and no second notebook to keep in step with the diary. Save it and the note is on the appointment, and in the patient's record, at once.

The diagnosis is coded in the same pass

Search the problem and pick the term, and the app brings the rest of the coding in with it — the site, which side, how severe — with the chosen term heading the narrative automatically. So the note reads as a clinical record and stays something the practice can search, count and audit, without a second pass over the list months later. The reason captured at booking is already in the box when the note opens, so the clinician begins from what the patient came for.

Written once, kept as written

A saved clinical note cannot be edited. Open it again and the app shows it back read-only, with the clinician's name on it and the time it was written.

VeriPath Health Clinics — a saved note read on the appointment it belongs to: the author, the time it was last updated, the note itself and a single View Note link

There is no edit control, because the account of a consultation should be the account given on the day. Anything that changes is written as a new entry beside the first.

Every note in one place

The patient's record lists the notes newest first — the date, who wrote it, the appointment it belongs to and the coded term.

VeriPath Health Clinics — the clinical notes list on a patient's record: date, author, appointment, coded term and a view for each note

A patient's history reads as one sequence rather than a set of files held in different hands.

Read by the clinical team only

The note is encrypted at rest and shown to clinicians and the practice manager — not to reception. A patient's clinical detail is not spread across every screen in the building.

The record an inspection asks for

Notes written at the time, and coded the same way every time, are the evidence a CQC inspection asks for. The app counts note completion and coding as the work happens, so that evidence is the clinic's ordinary record rather than a folder assembled in a hurry.

Part of the VeriPath Health Clinics set

Appointments — the list, the booking and the outcomes this note is written against.
Recording Symptoms — how the reason for the visit is captured and coded at the desk.
The full Health Clinics set