> ## Documentation Index
> Fetch the complete documentation index at: https://docs.ndumed.co/llms.txt
> Use this file to discover all available pages before exploring further.

# Record vitals, clinical notes and diagnoses

> Record vital signs with automatic BMI and range flags, write and sign clinical notes from templates, add amendments, and code ICD-10 or ICD-11 diagnoses in NduMed.

Vital signs, clinical notes and diagnoses are recorded in panels on the encounter screen. Open the patient's encounter from **Clinical** first. Nothing in these panels can be changed after the encounter is closed.

## Vital signs

Doctors and nurses can record vitals.

| Field | Unit |
| - | - |
| Temperature | °C |
| Systolic / Diastolic blood pressure | mmHg |
| Pulse | bpm |
| SpO₂ | % |
| Respiration | breaths per minute |
| Weight | kg |
| Height | cm |

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.

> [!NOTE]
>
> 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.

> [!NOTE]
>
> 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**.

## Visit summary

Select **Visit summary** on the encounter screen for a printable summary of the encounter.


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