Patients

The patient record is the anchor for everything else in Med: appointments, consultations, consent sessions, recordings, generated paperwork and uploaded files all hang off it. It is also where the identity details that print on signed documents live, so it is worth getting right once rather than at the chair side.

Find it under Patients → Patients.

Adding a patient

Press New Patient. The form is headed Patient details, with the reason for it stated: “Identity data is reused when generating clinic paperwork.”

The identity fields are required, because consent paperwork prints them:

Group	Fields
Identity (required)	Last name, First name, Date of Birth, CNP, ID document series, ID document number
Address	Street, Number, City and County (required); Block and Apartment (optional)
Contact and record	Email, Phone, Medical Record Number
Notes	Notes

The CNP and ID document are checked for format. Press Create Patient.

If another record already holds the same CNP, Med stops and says “This CNP is already on file”, with a link to the existing record — including an archived one, which you can restore instead. Open the existing record rather than registering the patient a second time; if it really is a different person, check the number and use Create the patient anyway.

Older records

A record created before the name and address were split into parts keeps the name or address it has on file — the form shows it as “Currently on file” — until you fill in the parts to replace it.

Patients who cannot sign for themselves

Where someone signs on the patient’s behalf — a parent for a minor, a carer for a patient who cannot sign — press Add a caretaker (“Someone who cares for the patient and signs the documents on their behalf.”). For a minor the block is shown already, headed Legal representative (minor patient); otherwise it is Caretaker / legal representative. It holds:

• Legal representative name and Legal representative relationship (for example Mother).
• Legal representative ID is the document that empowers them: a notarial power of attorney, a court order, or the identity document produced. The patient’s details label this Representation document.
• The representative’s own CNP, address, ID series and ID number are separate fields, because the representative signs handover and refusal forms in their own name and those documents print their details.

Cannot consent for themselves records a standing fact about an adult — under guardianship, or unable to decide for themselves — not a passing state on the day. While it is set, documents cannot be signed until a legal representative is on file.

A consent session can also capture a representative on the spot, and what you enter there lands on the patient record.

Finding a patient

The patient list shows how many patients you have, how many were added in the last 30 days, and how many have upcoming appointments. To find someone:

• Search by name, CNP, phone, email or medical record number. Diacritics are optional and the words of a name can be typed in any order.
• Sort by clicking the Name or Date of birth column headings.
• Switch the Roster filter between Active patients and Archived patients. If a search finds nobody active but matches an archived patient, Med shows the archived match, marked, rather than no results.
• The list pages at 24 patients.

Columns show the name, date of birth, the last four digits of the CNP, the record number, an appointment count with how many are upcoming, and the email.

Same names

When two patients share a name, Med marks the row: “Several patients share this name - check the date of birth.” and emphasises the date of birth and the CNP digits. Check them before you open a record, and certainly before you generate a document.

The patient’s page

The header shows the patient’s name, age (from a recorded date of birth) and record number, a Patient details button, and one primary action:

• Start the visit — or Start the visit for today’s appointment when the patient is booked today, which links the visit to that appointment. With several bookings today, Choose today’s appointment: lets you pick one.
• Continue the consultation when a visit is already open.

Below it, the page has tabs:

Tab	What it holds
Patient summary	Now — the facts that bear on today’s consultation: active problems, current medication, allergies and the latest diagnosis. To resolve — what needs your attention for this patient, such as a consent still to sign. Latest visits.
Consultation	The consultation note for the open visit — see below.
Visits	The Clinical history: visits, and appointments that host no visit, newest first. Select a visit to see its note, diagnosis, treatment, procedure and documents. Search and filter by kind (Visits, Diagnoses, Treatments, Documents), by date, and by status — In progress, Needs finishing, Finished.
Documents	The patient’s paperwork, one dossier per visit, and uploaded PDFs. See Clinic forms and documents.
Vaccinations	Shown only when your clinic has the vaccinations module — see below.

On every tab but the summary, a Clinical context strip keeps the active problems, medication and allergies in view.

Patient details opens a drawer with the contact and identity details, the legal representative when there is one, notes, and the actions that manage the record: Edit patient details, Edit my clinic identity (“CNP and ID details used on clinic forms you create.”), Archive patient and Delete Patient.

Writing the consultation

On the Consultation tab, a patient with no open consultation offers How do you want to start? — an Empty consultation, or Use a template with the suggested section titles Reason for the visit, Patient history, Clinical examination, Diagnosis, Treatment plan and Recommendations, with no text in them. Starting opens a visit; opening the tab does not.

The note is written in sections you can add, rename, reorder and remove, with simple formatting and images (JPG, PNG or WebP, up to 15 MB each). It saves as you write. From the note:

• Prepare the consent — “For a procedure proposed in this consultation.” It saves the note and opens the consent session for this patient, or the visit’s consent documents if the visit already has them. It generates and signs nothing by itself.
• Preview shows the whole consultation.
• Finish the consultation closes it, once any consent paperwork the visit owes is signed. A finished consultation can no longer be changed.

The note is a clinical record, not a document the patient signs. Preparing a consent without writing a note is a separate action: New consent.

The clinical record

Now and the clinical context strip read the patient’s clinical record: diagnoses, medication and allergies. Each opens a dialog — All diagnoses, Medication, Allergies and reactions — where the patient’s treating clinician can add entries, correct them, mark a diagnosis resolved or a treatment stopped, and record No known allergies as a confirmed answer rather than an empty list.

Nothing is overwritten or deleted: “Every change creates a new version and keeps the history.” An entry recorded by mistake is marked as entered in error and stays counted in the history. Anything that could not be established is shown as such, with a prompt to check it with the patient.

Only the treating clinician can change the clinical record. Everyone else who can open the patient reads it: “Read only. Only the patient’s treating clinician can change the clinical record.”

Uploading a patient’s documents

On the Documents tab, Upload document takes Choose PDF, an optional title, then Upload.

• PDF only. Med checks both the file name and the file’s contents, so a renamed file is rejected.
• The default size limit is 10 MB per file; your platform administrator can change it.
• The file is indexed into your clinic’s clinical knowledge library as patient data, which is what makes its contents available to the consent engine and to search. While that happens the row shows “Reading the document…”; if it fails you see “The document could not be read - upload it again.”
• Each row offers Download and, for the treating doctor, Delete. Deleting removes the file and its indexed copy.

Uploaded patient documents stay inside your clinic. They are marked as patient data, which also keeps them out of the protocol suggestions offered when you author approved consent content.

Vaccinations

Where your clinic has the vaccinations module, Patients → Vaccinations follows up patients who need to come back for a vaccine. Nothing decides automatically who should be vaccinated: every follow-up is entered by a person and confirmed by a physician.

• Configuration (clinic administrators) lists the Vaccines followed; add, edit or archive a vaccine, and Add a patient to a vaccine’s list. “The follow-up is saved as „Awaiting medical confirmation”. Nobody is contacted until a physician confirms the plan.”
• Monitoring lists, per vaccine, the patients to follow up, with overdue and this-week counts. Opening a patient lets a physician Confirm the plan or Reject plan, change the agreed due date, and Record the administration.
• Prepare the notification shows a preview of the message. Med does not send it: send it through your clinic’s usual channel, then confirm with **I sent it
  • mark as contacted**.
• A recorded dose cannot be edited afterwards — check the date and the lot before saving. Doses given elsewhere, for example from the vaccination booklet, can be recorded too.

The patient’s Vaccinations tab shows their follow-ups, recorded doses and the change history.

Who can see and change what

• Everything is scoped to the clinic you are working in. A patient belonging to another clinic is not found — not “forbidden”, simply absent.
• By default a doctor sees the patients they created. If your clinic turns on Shared patient roster (under Medical facility), every doctor and assistant in the clinic sees all of its patients; editing still stays with the doctor who entered the patient and the clinic administrator.
• A clinic administrator sees across the clinic. Without a shared roster the view is read-only, and Med labels it: “Clinic admin view - read-only. Only the treating doctor can edit this record.”
• A scheduling seat sees appointments only, with the patient’s name and phone — never the patient’s record.

If you work at more than one clinic, check which one you are in before you create a patient — the Hub header shows the current organization and lets you switch. Med also protects you from getting this wrong in a second tab: if the active clinic changed since you opened a form, the save is refused with Your active clinic changed and nothing is written.

Archiving a patient

Archive patient in Patient details takes the patient off the roster: “Nothing is deleted — the record and its signed documents stay.” An archived patient is found under Archived patients, and in searches that match nobody active. To start a new visit, restore them first with Restore to roster.

Archiving is the ordinary way to tidy the roster. Deleting is erasure.

Deleting a patient

Delete Patient in Patient details, then confirm. Med warns you: “This permanently deletes the patient record, its appointments and visits, every recording and uploaded document, and their files.” If the patient has signed consent documents, Med names how many and asks you to confirm that they will be destroyed — “which the patient signed and the clinic may have to produce later” — before Confirm Delete is enabled. A document that is being signed at that moment stops the deletion.

In practice it removes, with no undo:

• the patient record and their appointments;
• their visits, audio recordings, transcripts and clinical record;
• their generated and signed documents;
• their uploaded PDFs;
• the indexed copies of all of the above in your clinic’s knowledge library, and the stored files themselves.

Download anything you are obliged to retain before deleting. If a patient is exercising a data-protection right, treat this as the deletion step and keep your own record that it was done.

Things Med does not offer here

• There is no way to merge two patient records. If you have created a duplicate, move what you need and delete (or archive) the duplicate.
• Whether a patient may be pregnant or cannot read is not recorded on the patient record. Where such a circumstance affects consent, say so in the consultation and check the generated wording before you sign.