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Adding Clinical Information, Notes and Patient Directions

How to record the diagnosis, allergies, and notes that travel with a prescription.

Clinical Information is the 2nd of the 4 sections in the prescription form, alongside Patient Information, Prescription Items, and Delivery & Consent.

Complete the clinical fields

  1. Enter the Diagnosis
    Provide information on the patient's diagnosis. This field is required.

  2. Enter the Allergy Warnings
    Provide all information on the patient's allergies. This field is required. If there are none, record that clearly.

💡 Tip: If a patient has no known allergies, write this in rather than leaving a note for yourself to fill in later, for example "No known drug allergies" or "NKDA".

🗒️ Note: The Diagnosis and Allergy Warnings you enter here are carried through to the Sign and Issue Prescription summary, so double check them before you issue.

Add notes for the patient and pharmacy

  1. Add Notes to Patient (optional)
    Use this for additional information you want to share with the patient.

  2. Add Notes to Pharmacy (optional)
    Use this for additional notes for the pharmacy. These are only visible to the pharmacy.

💡 Tip: Notes to Pharmacy are the right place to explain anything unusual, such as a dose above the normal range, so the pharmacy has the context it needs.

🗒️ Note: Patient directions for how to take each medicine are entered separately, in the Dosage & Duration Instructions field for each prescription item.

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