Vital signs
Doctors and nurses can record vitals.
NduMed calculates BMI from weight and height and flags out-of-range readings as high or low. You can record vitals more than once during an encounter.
Clinical notes
Notes have two statuses: Draft and Signed.1
Start a note
Select Start a note. Optionally choose Start from template (for example General consultation, Progress note or Nursing note) to pre-fill the text.
2
Write and save
Enter a Title and the Note, then select Save draft. Use Edit draft to keep working on it.
3
Sign (doctors only)
Select Sign note and confirm. Once signed, a note cannot be edited.
4
Correct a signed note
Select Add amendment on the signed note. Amendments are kept with the original so the record shows what changed.
Nurses can write and save notes but cannot sign them. Only doctors can sign.
Diagnoses
1
Search for a code
In Diagnoses, type at least 2 characters of an ICD-10 or ICD-11 code or description.
2
Add it
Select Add. The first diagnosis on an encounter becomes the primary diagnosis automatically.
3
Adjust
Use Make primary to change which diagnosis is primary, or Remove to delete one. Each encounter always has exactly one primary diagnosis once any diagnosis is added.
If a code you expect is missing, your hospital’s diagnosis code list may need updating. Contact NduMed support.
Note templates (administrators)
Administrators manage note templates at/admin/note-templates: Name, Specialty and Body. Templates can be added, edited and deactivated. Deactivated templates no longer appear in Start from template.