Drafts only use chart information that a clinician has reviewed. Documents and facts are where that review happens.
Upload a document
- Open the patient and go to Documents.
- Choose Upload document and pick a PDF, PNG, JPEG or text file, such as a referral letter or lab report.
- Terra extracts the text. Native PDFs are read directly; scanned pages and photos use text recognition.
- Open Review text, compare the extracted text with the original, correct it and save the review.
A reviewed document can be selected as a source for a draft. A document still marked needs review cannot.
Add or approve a fact
Facts are structured entries: allergies, medications and problems.
- Go to Facts and choose Add patient fact, or accept one proposed from a reviewed document.
- Enter the details, such as the substance and reaction for an allergy, or the drug, dose and frequency for a medication. Medication names can be matched to RxNorm.
- Approve it.
Approved allergies and active medications are always included in drafts. Active problems are included when you turn them on in the visit's source picker.
When two sources disagree, for example two different doses, Terra shows the conflict so you can choose the current one. The other entry is retracted, not deleted, and the decision is kept in history.
Correcting a fact
Editing or retracting an approved fact creates a new revision. Any draft that was running with the old value is discarded as stale, so a corrected allergy can never be overwritten by an older draft.
Retiring an original file
After a document has been reviewed, a clinician who manages the practice can remove the original upload from active storage: Review text → Original file retention. The reviewed text, extraction results and signed notes are kept. Originals that support a signed note cannot be retired, and a hold blocks retirement until it is released.
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