# Medical Records

The **Medical Records** module in Unite EMR provides healthcare professionals with a comprehensive platform to access, update, and manage patient information efficiently. This screen supports the full spectrum of clinical documentation, ensuring that both past and ongoing treatment data are available in one place. This module covers every aspect of a patient’s medical journey, from initial diagnosis to treatment plans, medication, and follow-up visits.

***

## Start Consultation

To begin a consultation, select the patient's visit from the [Nurse or Doctor’s Queue](/uniteemr/application-modules/patient-queue/nurse-or-doctors-queue.md) (**Current** and **Past Medical Records** screens). A confirmation pop-up will appear:

<figure><img src="/files/uTm0DxHRXKx1Fig90jdA" alt=""><figcaption></figcaption></figure>

* **No**: Allows you to view previous records in read-only mode, without calculating Turnaround Time (TAT).
* **Yes**: Starts the consultation, enabling doctors to document and calculate TAT.

### **Alternative Start Option**

You can also start a consultation from the **Appointment Information** pop-up in the **Scheduler** screen.

* **From the Scheduler**:

  <figure><img src="/files/iqKk51ZdE3K6mNcLp3lB" alt=""><figcaption></figcaption></figure>

  * Navigate to the **Scheduler** screen, then click an appointment card to open the **Appointment Information** pop-up.
  * Select the **Start Consultation** button.
  * A confirmation pop-up will appear. Click **Yes** to confirm and proceed with the consultation.

{% hint style="info" %}
If the patient has high-severity highlights, the **Patient Highlights** pop-up will display critical information automatically, alerting nurses and doctors before the consultation. To know more, navigate to the [**Highlights**](/uniteemr/application-modules/medical-records/more-action/patient-highlights.md) section.
{% endhint %}

***

## Overview

The **top panel** of the **Medical Records** screen shows essential patient details, such as the patient's name and PIN. If a package or discount card is associated with the patient, the top panel displays a visual indicator. The **right panel** includes additional information like the patient’s name, gender, date of birth, age, mobile number, visit date, and the name and date of the last modification. The doctor’s name and visit date are also displayed on the right.

The **Allergy/Highlights panel** notifies users of critical information by displaying **Allergies** in red and **Highlights** in orange.

<figure><img src="/files/4d7U3ONFq4KvR8YB3WXQ" alt=""><figcaption></figcaption></figure>

If the patient has insurance, the top panel displays basic insurance information, including the insurance provider's name, policy number, expiration date, payer ID and the post office type (e.g DHA, Riayati and Shafafiya) information.

<figure><img src="/files/r0IqhJYsjBUtxYcrx5NN" alt=""><figcaption></figcaption></figure>

If the **Documentation Completed** option is enabled for a doctor user, the **Is Documentation Completed?** checkbox will be visible in **Medical Records**. This setting is used to lock the medical records once documentation is finalized, preventing further edits or overwriting of existing information.

{% hint style="info" %}
A visual indicator appears for a patient visit when it is marked as [**Is Documentation Completed**](/uniteemr/application-modules/scheduler/filter.md#documentation-not-completed)
{% endhint %}

{% hint style="warning" %}
Medical Records cannot be edited once the doctor marks the **Documentation Completed** option for the visit.
{% endhint %}

***

## Steps to Capture Details in Medical Records

* **Medical Records** screen includes the following tabs to view and document patient information:

<table data-view="cards"><thead><tr><th align="center"></th><th data-hidden data-card-cover data-type="files"></th><th data-hidden data-card-target data-type="content-ref"></th></tr></thead><tbody><tr><td align="center"><strong>Diagnosis</strong></td><td><a href="/files/SJFDJrF8c4gA8x7ox1wV">/files/SJFDJrF8c4gA8x7ox1wV</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/y04oCKp0DOjPZ4Lc0pK7">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/y04oCKp0DOjPZ4Lc0pK7</a></td></tr><tr><td align="center"><strong>Casesheet</strong></td><td><a href="/files/UA4GU7H5I6iIwm2ZlCjf">/files/UA4GU7H5I6iIwm2ZlCjf</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/TJGYkVPrlIueemkPP2aH">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/TJGYkVPrlIueemkPP2aH</a></td></tr><tr><td align="center"><strong>Medication</strong></td><td><a href="/files/QWgOwuv33DP3mc9fqzrg">/files/QWgOwuv33DP3mc9fqzrg</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/ssEGoyV1kDdqXTtMO7fV">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/ssEGoyV1kDdqXTtMO7fV</a></td></tr><tr><td align="center"><strong>Test Result</strong></td><td><a href="/files/QWgOwuv33DP3mc9fqzrg">/files/QWgOwuv33DP3mc9fqzrg</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/9q7F5eMLjMIlO19ulbId">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/9q7F5eMLjMIlO19ulbId</a></td></tr><tr><td align="center"><strong>Glass Prescription</strong></td><td><a href="/files/SJFDJrF8c4gA8x7ox1wV">/files/SJFDJrF8c4gA8x7ox1wV</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/mjQRRPWVlzG3iU1R2roc">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/mjQRRPWVlzG3iU1R2roc</a></td></tr><tr><td align="center"><strong>Journey</strong></td><td><a href="/files/UA4GU7H5I6iIwm2ZlCjf">/files/UA4GU7H5I6iIwm2ZlCjf</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/8uZtqJNJ9SSe1g4L7iXI">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/8uZtqJNJ9SSe1g4L7iXI</a></td></tr><tr><td align="center"><strong>Document</strong></td><td><a href="/files/UA4GU7H5I6iIwm2ZlCjf">/files/UA4GU7H5I6iIwm2ZlCjf</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/OjVuVsQpsfFt7p4wC0nF">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/OjVuVsQpsfFt7p4wC0nF</a></td></tr><tr><td align="center"><strong>Precheck</strong></td><td><a href="/files/QWgOwuv33DP3mc9fqzrg">/files/QWgOwuv33DP3mc9fqzrg</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/mWiNnuQPXYgtomClySfd">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/mWiNnuQPXYgtomClySfd</a></td></tr><tr><td align="center"><strong>Vaccination</strong></td><td><a href="/files/SJFDJrF8c4gA8x7ox1wV">/files/SJFDJrF8c4gA8x7ox1wV</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/vR74Kk3K7xNmwRsgGndL">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/vR74Kk3K7xNmwRsgGndL</a></td></tr><tr><td align="center"><strong>Treatment Plan</strong></td><td><a href="/files/SJFDJrF8c4gA8x7ox1wV">/files/SJFDJrF8c4gA8x7ox1wV</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/e1nE3GkPTUWZFdaelXuH">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/e1nE3GkPTUWZFdaelXuH</a></td></tr><tr><td align="center"><strong>Dental Chart</strong></td><td><a href="/files/UA4GU7H5I6iIwm2ZlCjf">/files/UA4GU7H5I6iIwm2ZlCjf</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/qmpIoTh4oJ9dvhKw64ZS">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/qmpIoTh4oJ9dvhKw64ZS</a></td></tr><tr><td align="center"><strong>Family &#x26; Social History</strong></td><td><a href="/files/QWgOwuv33DP3mc9fqzrg">/files/QWgOwuv33DP3mc9fqzrg</a></td><td><a href="/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/cBKKY2ur2lY1flfoVAzM">/spaces/WQ5ypNBejmFIr9zwp0Pi/pages/cBKKY2ur2lY1flfoVAzM</a></td></tr></tbody></table>

* After filling in the necessary tabs, click the **SAVE** button to complete the consultation. Alternatively, use the **SAVE AND CONTINUE** button to save the document while continuing to capture further details.

***

## Video Tutorials

{% columns %}
{% column %}
{% embed url="<https://youtu.be/ayOhrtGmIqY>" %}
Diagnosis & Medication
{% endembed %}
{% endcolumn %}

{% column %}
{% embed url="<https://youtu.be/A9rhQvwlCHw>" %}
Journey & Documents
{% endembed %}
{% endcolumn %}
{% endcolumns %}

{% columns %}
{% column %}

{% embed url="<https://youtu.be/BOOpnqbJ3GU>" %}
Family & Social History
{% endembed %}
{% endcolumn %}

{% column %}

{% endcolumn %}
{% endcolumns %}

***


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