The record brief

The record brief is a short, sourced summary of what the chart contains, ready before you walk into the room.

Prepare the brief

1. Open the patient's Overview, or open a visit for the patient.
2. Choose Prepare record brief. The first preparation is explicit; after that, Terra refreshes the brief in the background when its sources change.

What it contains

• Reviewed facts (allergies, medications, problems) with their structured fields and where each came from.
• Excerpts from approved documents.
• Excerpts from verified signed notes.

Each entry shows its source, version and date, and opens the full record. The brief holds up to 50 facts, 10 documents and 5 signed notes. When something is left out because of these limits, the brief says so.

What it does not contain

• Unsigned draft text. Editing a draft does not change the brief.
• Interpretation or recommendations. The brief quotes the record; it does not judge it.

The brief is for reading. It is not added to the note and is not sent with a draft. Drafts get chart context through the visit's own source picker.

When the brief is stale

If a source changes, for example a fact is corrected or a note is amended, the affected entry disappears from the brief straight away and the brief is labelled stale until it refreshes. An older value is never shown as current.

What changed since the last signature

The Overview also lists literal changes since the patient's last verified signed note: new or corrected facts, new documents and amendments. Mark them as reviewed when you have read them; the receipt is private to you.