Concept explainer
What the record holds
Explains the kinds of clinical information the record keeps for a patient and how each entry is attributed to an author and a time.
The patient record is the one place a clinician opens to see and act on a patient's whole clinical history. This page sets out the kinds of clinical information the record keeps, and how each entry is attributed to the person who made it and the moment they made it.
Where the record lives
Atlas holds the patient record. It is the one tool that keeps a patient's actual health data, and every other tool asks Atlas for it rather than keeping a copy.
One record per patient
The patient record is the durable account of a patient across every visit. One record exists per person, and it belongs to the patient rather than to any site or organisation. It exists once across every hospital that runs Pensieve and follows the patient. A clinician treating the patient reads the same history at any site that runs Pensieve.
Diagnoses, orders and charges attach to a visit within the record. The record therefore reads as a history of episodes rather than a flat pile of entries. The page on the record across sites covers how one record stays consistent wherever the patient is seen.
What the record keeps
The record gathers several kinds of entry for one patient. Each kind has its own page in this section.
Coded conditions recorded against a visit and carried forward as ongoing problems.
Observations and structured notes captured through the hospital's own forms.
Scanned documents, images and files attached to the record.
Studies such as X-ray, CT and MRI, read in the image study viewer.
The urgency category recorded for a patient's presentation.
The consent a patient gives, held against the record.
The attributed account of who opened the record and when.
Author and time
Every entry in the record names the person who made it and the moment they made it. The name is the staff member's own identity, drawn from their sign-in, so an entry always traces to a real person.
Attribution holds on a shared screen
On a shared ward workstation, each member of staff signs in as themselves. Each person's session is their own, so the record stays truthful about who acted even when several people use one screen through a shift.
The record keeps its history. An entry is added rather than overwritten, and a correction is recorded as a new version while the earlier one stays visible. The page on corrections and amendments sets out how an entry is amended.
Identity in the record
Alongside the clinical entries, the record holds the patient's identity: name, date of birth, contact details and address. It keeps two facts about sex, a clinical value that guides safe dosing and reference ranges, and an administrative value used for identity. It holds a blood group chosen from a fixed set of groups.
A patient registered in an emergency carries a temporary identity until their details are confirmed, and the record enriches to a full identity once they are known. Identity moves one way, from unidentified to identified, so a confirmed identity stays settled.
Reading the record
Access to the record is decided for every read, from the person's role together with their relationship to the patient in front of them. The record a person opens shows the entries their role and the patient's admission entitle them to. The page on how a permission is decided sets out the decision in full.
Common confusions
Does the record belong to a site or to the whole hospital?
The record belongs to the patient. One record exists per patient with no owning hospital and sits outside the tenancy structure, so care at any site treating the patient draws on the same history.
Where are a patient's observations kept?
Observations and structured notes are captured through the hospital's own forms, and the completed forms sit in the record.
Can an entry be changed after it is saved?
A correction is recorded as a new version, and the earlier entry stays visible, so the record stays accurate and traceable.
Read how diagnoses and ongoing problems are recorded.