GlossaryNutrition · Management
Digital clinical record
An electronic record of medical history, clinical data, and patient notes.
Definition and context
An electronic record of medical history, clinical data, and patient notes. This definition summarizes the main objective of the concept so that any reader can quickly identify how to apply it.
Centralizes medical history, diagnoses, plans, lab results, and follow-up in a secure, accessible digital system.
Why is it relevant?
Improves continuity, reduces errors, and enables quick decisions with up-to-date information.
Applied example
How to apply it in Almendra
- Save the history and notes in Almendra for access at each session.
- Attach labs and progress photos; share summaries with the patient when appropriate.
- Set up medication/allergy alerts in the profile.
Key recommendations
- Record key data in a structured format.
- Update after each consultation and medication change.
- Maintain security and informed consent.
- Use standardized fields for quick searches.
- Back up and audit access periodically.
Frequently asked questions
How do I prevent data loss?
Use systems with backup and access control; update immediately after the consultation.
Can I share the record?
Only with the patient's consent and in compliance with privacy regulations.
Related terms
Next step
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