Patient record · Marina CostaSummaryVisitsDocumentsAnamnesis
AllergiesDipyrone
Last visit12/11
Blood pressure12/8
VisitICD-10ProfessionalStatus
Follow-up visitJ30.4DPDra. Paula ReisSigned
First visitJ45.9DPDra. Paula ReisSigned
Exam reviewZ01.7DCDr. Caio LimaDraft
Anamnesis answered by link11/11
Follow-up visit recorded and signed12/11
Anamnesis by linkThe patient answers on the phone before the visit.
Official ICD-10The DATASUS table inside the visit.
3D avatarMark on the model what was treated.
Locked sheetFinished sheets are locked and audited.
Before, during and after the visit
1
Before
The anamnesis arrives answered by link, and the record opens with the history, the allergies and the last visits.
2
During
The professional records the visit with a template, the ICD-10, the vital signs and the photos of the case.
3
After
The visit is finished and locked, and the prescription and the exam request go out signed.
A visit recorded in minutes
Start from a template of the clinic, search the ICD-10 by code or by name and record the vital signs the clinic follows. Each item of the clinical summary, like allergies and conditions, only enters when the professional confirms it.
Visit templates by specialty
ICD-10 from the official DATASUS table
Vital signs with a chart over time
Allergies and conditions in the patient summary
Anamnesis the patient fills in on the phone
Build the clinic forms and send a link. The patient answers before the visit, with automatic saving, and the schedule shows when it is ready. It can also be filled in with the patient during the visit.
Forms built by the clinic
Sent by WhatsApp or e-mail
Answers straight into the record
Evolution with dated photos
The visits, notes and photos of a case in one line of time. Put photos of different dates side by side, and ask the patient for new photos by a secure link.
Before and after ready to print
Photos and videos by secure link
Burn recovery compared over time, as a draft for review
Draft to support the analysis of the professional, marked for review.
Compare photos Add to the record
Procedures on the 3D avatar and the odontogram
Record each procedure by region of the face and body, mark it on the 3D model and plan the next sessions. Dentistry has the odontogram with surfaces and the periodontogram.
Product and batch on each procedure
Dose limits set by the clinic, with a warning
Adverse events with dated follow-up
AI that supports, the professional who decidesOn request
Dictate the evolution in a short audio, record the visit with the patient's consent, and receive a draft of analysis of images and videos. Everything arrives marked for review and never becomes a diagnosis on its own.
Dictation of the evolution
Visit recording with consent
Analysis support as a draft
And more in this module
Records overview
Indicators of what needs attention.
Clinic protocols
Sheet templates and the clinic's own protocols.
Exams linked to the visit
The exam request stays with the visit that asked for it.
Shared care
Several professionals on the same patient, each with a council number.
Summary for the patient
A link with the procedure and the aftercare.
Access history
Who opened each record and when.
Frequently asked questions
Does the AI make diagnoses?
No. The analysis support prepares a draft that arrives marked for the professional's review, and it never becomes a diagnosis on its own.
Can I build my own forms and templates?
Yes. The clinic builds its anamnesis forms, its visit templates and its protocols.
Which ICD-10 table is used?
The official table published by DATASUS, kept up to date by Verbum.
Can a finished visit be changed?
The finished sheet is locked. Changes are made by an amendment, and unlocking, printing and sharing are recorded in the audit trail.