HistoryOsis — Clinical Intake

A

A — Demographics

Patient ID & admission details

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Full Name

MR Number (Medical Record No)

Age

Sex

Bed Number

Department

Admitted Via

Status (optional)

Tags (optional, press Enter)

Occupation (note exposure/lifestyle risk)

Residence (urban/rural; district)

Date of Admission

Time of Admission

Informant (who gave history; reliability)

Additional Demographics

B

B — Structured History

PC, HOPI, ROS, Comorbidities, PMH, FH, SH

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Chief Complaints (PC) + HOPI

Select a complaint or type a custom one, then tap + Add. Each complaint gets its own HOPI card.

Select Complaint

Or Custom

Review of Systems (CVS, Resp, GI, GU, Neuro, MSK, Derm, Psych, Haem, Endo)

Select System Symptom

ROS Narrative

ROS Custom Entry

Comorbidities (Known chronic conditions)

Select Comorbidity

Comorbidities Narrative / Custom

Past Medical & Surgical History (diagnoses, operations, transfusions)

Past Medical Conditions

Past Surgical History

Drug History (current meds, dose, duration)

Allergies (drug, food, reaction type)

Immunisation History

PMH Custom Entry

Family History (first-degree relatives; age of onset, cause of death)

Select Condition

Family History Narrative

FH Custom Entry

Personal & Social History (smoking, alcohol, diet, exercise, travel, living)

Smoking

Smoking Details

Alcohol

Recreational Drugs

Diet

Exercise

Travel History (last 6 months)

Living Situation

Functional Status / ADLs

SH Custom Entry

C

C — Examination

General + system-specific findings

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Vital Signs

BP (mmHg)

Pulse (bpm)

Shock Index

RR (/min)

SpO₂ (%)

Temp (°F)

GCS

Height

Weight

BMI (auto)

NEWS2 (uses the vitals above)

Supplemental oxygen

Consciousness

Use SpO₂ Scale 2 (target 88–92%, e.g. COPD with hypercapnic failure)

Enter vitals to see the NEWS2 score.

Decision support only. Clinical judgement and local protocols apply.

General Examination (appearance, pallor, jaundice, cyanosis, clubbing, lymph, oedema)

General Appearance

Pallor

Jaundice

Cyanosis

Clubbing

Lymphadenopathy

Oedema

Other Signs (koilonychia, spider naevi, xanthomata, etc.)

System-Specific Examinations

Select systems to examine. Specific findings fields appear for each.

Add System

Examination Custom Notes

D

D — Investigations

Labs, imaging, endoscopies, biopsies

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App Locked