Inpatient EHR Clinical Assessment and Notes - hmislk/hmis GitHub Wiki

Inpatient EHR — Clinical Assessment and Notes

Clinical Assessment is the doctor's ward-round note for an inpatient. Each assessment is a structured encounter record that can carry a clinical narrative, diagnoses, medications, investigations, images, and procedures. Multiple assessments can be created for a single admission — one per ward round or clinical event.

Page (new/edit): Admission Profile → Clinical Data → Clinical Notes → New Assessment
Page (list): Admission Profile → Clinical Data → Clinical Notes
XHTML: /inward/inward_clinical_assessment.xhtml (new/edit), /inward/inward_clinical_assessment_list.xhtml (list)
Controller: InpatientClinicalDataController.saveClinicalAssessment()
Privilege: InpatientClinicalAssessment

Assessment Form

The assessment form is tabbed. Tabs visible depending on what has been entered:

Clinical Notes Tab

  • Free-text notes area — the main clinical narrative. Supports abbreviation-aware autocomplete: when the cursor is after Hx:, completions are drawn from history terms; after Ex:, from examination terms; after Ix:, from investigation terms; after Rx:, from treatment terms.
  • Height, Weight — recorded and BMI is auto-calculated
  • Blood Pressure, Pulse Rate, Respiratory Rate, SpO₂, Temperature — vital signs
  • Diagnoses — structured diagnosis items (linked to the item master)
  • Procedures — procedures performed during this encounter

Medicines Tab (Ward Medications)

Available after saving the assessment. Add ward medications linked to this specific encounter. See also Inpatient EHR — Ward Medications for admission-wide ward medications.

Discharge Medicines Tab

Available after saving the assessment. Add take-home prescriptions. See Inpatient EHR — Discharge Medications.

Assessment List

The list page (inward_clinical_assessment_list.xhtml) shows all assessments for the current BHT in reverse chronological order. Each row shows:

  • Assessment date and time
  • Clinician name
  • Summary of diagnoses
  • Actions: View, Edit (if not view-only)

Past assessments can be viewed but not edited if the viewOnly flag is set.

Templates

The assessment form supports Document Templates — pre-defined text templates that can be loaded and modified. Templates are managed by the DocumentTemplateController and are type DocumentTemplateType records. Selecting a template pre-fills the notes area with the template text, which the clinician then personalises.

Navigation

From the assessment page, the following navigation is available:

  • Save — save the assessment (disabled in view-only mode; requires InpatientClinicalAssessment)
  • Back to Assessment List — return to the assessment list for this BHT
  • Inpatient Dashboard — return to the Admission Profile
  • Patient History — open the patient's full OPD clinical history
  • Inward Medicines — navigate to the ward medications page for this encounter (disabled until the assessment is saved)
  • Discharge Medicines — navigate to the discharge medications page (disabled until the assessment is saved)

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