Clinical records
Examinations, charts, prescriptions, vaccinations and measurements — and who is allowed to see them.
The clinical side of a patient card carries examinations, anatomical charts, prescriptions, vaccinations, measurements taken over time, uploaded documents and clinical photographs.
Clinical records are special category data under GDPR art. 9 and KVKK art. 6, and they are handled on that footing throughout — separately grantable, encrypted at rest, and with exports written to the audit log.
What is in there
| Record | For |
|---|---|
| Examinations | What was found and what was done, per visit. |
| Anatomical chart | A chart appropriate to your speciality — a tooth chart for dental, a body map elsewhere. Findings attach to a location. |
| Prescriptions | What was prescribed, when, by whom. |
| Vaccinations | Doses given and when the next is due. |
| Measurements | Anything you track over time. The point is the series, not the single reading. |
| Documents and photographs | See documents and photographs. |
Who can see them
Only roles with the clinical records module enabled. Of the presets, that is owner, admin and doctor — secretary and accountant do not have it, which is the point of them being presets.
The module can also be scoped to own, so a visiting clinician sees the records they created rather than your whole list. See roles and permissions.
Exports
Exporting is its own permission, separate from viewing, and every export is written to the audit log. Someone who can read a record cannot necessarily take a copy of every record out of the building — and if they can, it leaves a trace.
This is the single most useful permission to withhold. Viewing is the job; bulk export almost never is.
Correcting an entry
Edit it. A clinical record that cannot be corrected is a clinical record that stays wrong, and correction is a right patients have. What matters is that the change is attributable — which it is, through the audit log.
Common questions
- Can a secretary book an appointment without seeing the notes?
- Yes. That is exactly what the split is for — appointments and patients are one module, clinical records another.
- Are clinical records included in a patient data export?
- Yes, where the person exporting has the permission. A subject access request that omitted the clinical record would not be an answer.