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Accurx Scribe in Desktop: How to Save to Record & Snomed Codes

This article covers how Accurx Scribe (powered by Tandem) saves back to the medical record

Shiro avatar
Written by Shiro
Updated over 2 weeks ago

How to save to record from Accurx Scribe

Once you have finished reviewing and editing your Scribe note, you should ensure you have the correct patient open in your medical record system and then click 'Save to record' in Accurx Scribe.


Confirm the patient demographics

After clicking 'Save to record' you will be shown the demographic information from the patient currently open in either EMIS or SystmOne and asked to confirm that it is the correct patient.


If needed, edit the note in the medical record

The EMIS and SystmOne APIs only allow Accurx Scribe to save notes as new record entries, not into open consultations, so they may be in a different format to how they would appear if manually entered by the user. This could result in clinical information being missed, or the note not being linked to relevant coding, prescriptions, referrals, investigations, or appointments.

If needed, you should ensure that you edit your notes in the medical record to add additional information, coding (e.g. problem codes) and to set the consultation type.

EMIS users can do this by editing the Scribe entry in the medical record. SystmOne users can do this by editing elements of the Scribe entry in the medical record (e.g. associate with problem codes, edit the text) or by adding additional coding, prescriptions and referrals as new note entries.

SystmOne users should also ensure they click 'Save' in the medical record to avoid discarding their Scribe note entry.


Snomed Codes

Accurx Scribe will initially support saving structured clinical observations to the patient record using standard SNOMED CT codes.

These observations are not automatically saved to the record. Clinicians must review them before clicking 'Save to record'.

The EMIS and SystmOne APIs only allow Accurx Scribe to save notes as new record entries, not into open consultations, which means that any medical record system warning related to these codes will not be triggered.

The first six supported codes are:

Clinical Observation

SNOMED CT Code

Units

Value Range

Systolic arterial pressure

72313002

mmHg

1–350

Diastolic arterial pressure

1091811000000102

mmHg

1–300

Body weight

27113001

kg

0.1–500

Standing height

248333004

metres

0.1–3.0

Tympanic temperature

415974002

°C

1.00–50.00

Peak expiratory flow rate

18491006

L/min

1–800

The following structured clinical codes are planned for release in future updates:

Clinical Observation

SNOMED CT Code

Units

Value Range

Peripheral oxygen saturation

431314004

%

0–100

Heart rate

364075005

bpm

0–300

Respiratory rate

86290005

respirations/min

0–100

Capillary refill time

15527001

seconds

0–60

Each of these values will be validated to ensure only clinically reasonable measurements are saved. Accurx will continue to validate and add further codes and structured fields over time to expand Scribe’s functionality.


If you need further assistance, you can contact our user support team using the speech bubble to the right hand of your screen 👉

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