Clinical Notes

Users stories

  1. Documentation of Care:
    • Actor: Clinician
    • Scenario:
      • As a clinician, I want to take a basic patient history using a structured form so as to document my findings and management plan.
  2. Continuity of Care:
    • Actor: Clinician
    • Scenario:
      • As a clinician, I want to use a structured form to maintain continuity of care.
      • The EMR system allows the clinician to review previous notes easily before each patient encounter.
      • This ensures a comprehensive understanding of the patient's medical history and ongoing management.
  3. Multidisciplinary Collaboration:
    • Actor: Clinician, Other Healthcare Providers
    • Scenario:
      • As a clinician collaborating with other healthcare providers, I want to use clinical notes to communicate effectively.
      • The clinical notes provide a standardized format for documenting patient information that can be easily shared among different specialties or departments.
      • This supports coordinated care and seamless handoffs between healthcare team members.
    • Referral and Consultation Notes:
      • Actor: Clinician, Specialist
      • Scenario:
        • As a clinician referring a patient to a specialist, I want to document the referral details.
        • The SOAP note includes a section for documenting the reason for referral, relevant patient information, and the specialist's recommendations.
        • This supports effective communication between primary care providers and specialists.
  4. Appointments:
          • Actor: Healthcare workers

            • As a healthcare workers i would like to schedule a patients appointment to review their progress at a later date.


              Technical approach

            Adopt with modifications what Palladium has as the clinical encounter to act as a generic OPD form in the refApp for a structured history and improved SOAP notes for unstructured history.