Active problems and issues​

Current medication issues​

Repeat medications​

Current allergies and adverse reactions​

Last three encounters

Details of allergies and adverse reactions

Current and past medication​

Dosage instructions​

Discontinuation details​

Additional information (i.e. linked problems)​

Medication issues

Immunisations and vaccinations​

May also contain information such as declined vaccinations

Direct encounters (i.e. GP visit)​

Unplanned encounters (i.e. out of hours clinic)​

Indirect encounters (i.e. GP reviewing test results)

Items of information relating to the care, health, or wellbeing of the patient​

Could include screening and past medical history

Any issue that is significant to a patient, and impacts their health or wellbeing.​

Disease​

Surgery​

Social issues (bereavement, unemployment)

Details of referrals to other services or departments

Clinical observations recorded by health professionals​

During assessment or direct care of patients​

Examples include:​

Scheduling and administering encounters​

Communication with other organisations​

Critical safety processes