Clinical records

Structured and paper prescriptions

Choose prescription format and distinguish items, documents, states and corrections.

Platform · Last verified:

Start from Prescriptions → Create Prescription or the patient's prescription section. Check whether patient context locks the selection.

FormatContentOutcome
StructuredProduct items; dosage/unit/frequency/duration/route/instructions; optional attachmentsParent and item states are tracked separately
PaperOne to five prescription images/PDFs; no medication itemsCompleted document record, not SOAP or regulatory prescription export

Structured prescription

  1. Select patient, prescription date and Structured format. Choose the correct eligible examination link.
  2. Add a product item and verify identity/concentration. A history suggestion only prefills a draft.
  3. Complete dosage, unit, frequency, duration, route and instructions from the clinician's prescription.
  4. Review the item list. Editing an item must not create a second copy.
  5. Create Prescription also validates an open changed item draft; resolve incomplete fields.
  6. Check parent/item state and the output document in detail.

Paper prescription

  1. Select Paper prescription, retaining patient/date.
  2. Upload/select the intended document. Check JPEG/PNG/WebP/PDF and the 10 MiB per-file limit.
  3. Preview order/readability. Wait for completion of offered phone capture/upload.
  4. Create and reopen documents/count in detail. Do not add product/dose items.

Ineligible files may be disabled in the picker. Paper format does not become regulatory prescription export, a SOAP prescription link or structured-prescription notification.

Editing, states and output

Save draft-item changes; failed saves retain the draft. Parent states may be draft/active/dispensed/completed/cancelled, while items are pending/dispensed/cancelled. Dispensing does not administer to the patient or automatically consume stock. Cancellation/deletion have separate access/state conditions; resolve unsaved work first.

Example: use paper format to retain a scanned prescription document. Use structured format to track medication items. Check patient, date, clinician and content in PDF/preview. Treatment/administration, files.

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