Clinical: diagnosis, orders and sign-off
The clinical role owns the medical record: the diagnosis, the preauthorisation course, lab orders, and the signed nephrologist report. This is the work that makes a session defensible clinically and fundable under SHA.
Roles: doctor and clinical lead.
Diagnosis
Section titled “Diagnosis”Record the diagnosis using ICD-11 coding. The code is what the SHA claim carries, so it must reflect the session actually delivered. The system offers the coded terminology rather than free text, so the diagnosis is structured and portable.
Preauthorisation course
Section titled “Preauthorisation course”Dialysis is authorised as a course, not one session at a time. From the patient’s chart you can see the active preauthorisation, how many sessions it covers and how many are used, so you know before the chair whether today’s session is funded. The system tracks the course state and blocks a claim path that would run past what is authorised.
Residual kidney function
Section titled “Residual kidney function”The patient’s chart carries the residual kidney function the nurse records: the interdialytic urine volume, the interval it was collected over, and the residual urea clearance when a urine and serum urea were done. A measurement older than a month is shown with its date and marked stale, and a recorded zero reads as anuric rather than as nothing recorded.
This matters most on a twice-weekly prescription. The adequacy targets the chart badges against depend on the prescribed schedule, and for any schedule other than thrice weekly the weekly figure includes the residual contribution, so a patient whose residual function has never been measured carries no weekly target at all and the chart says so. The system reports the number and its trend. It does not advise a change of schedule.
Lab orders
Section titled “Lab orders”Order labs from the patient’s chart. The system prints a requisition with a stable requisition id; a lost paper form is reprinted with the same id, never a new one, so a result that comes back weeks later still matches what was asked for. When the result arrives it is uploaded against that requisition, and its freshness and date are checked so a stale or mismatched result is caught before it reaches a claim.
The nephrologist report and wet-sign
Section titled “The nephrologist report and wet-sign”The nephrologist report is the clinical narrative for the session. An unsigned report re-assembles its auto-fill from the live session every time you open it; a signed one is frozen as the snapshot you approved. Signing applies your wet-sign marker. Sign only what you have reviewed: the signature is the record that a clinician stood behind the session.
What clinical does not do
Section titled “What clinical does not do”The system supports the clinician; it does not replace clinical judgement. It does not recommend a diagnosis, check drug interactions, or predict outcomes. See Clinical decision support for exactly what it does and does not do.