The resident’s medical record¶
The Medical Information tab of the resident record is their clinical record in Resthome. On a single page it brings together the measurements, the clinical status, the senses and risks, the devices, the diagnoses (ICD-10), the allergies, the medical contacts and the advance directives.
You find it on the resident record (Residents or Care app), in the Medical Information tab. The tab only appears for residents.
Access restricted to care staff
The Medical Information tab and the indicators derived from it (DNR badge, filters) are only visible to care staff. Changes to medical data are logged (traceability and GDPR compliance).
Above the tab, a set of stat buttons opens the other follow-up panels: Prescriptions, Care Plans, Notes, Katz, Vital Signs and Trends. The medical record described below, for its part, focuses on the resident’s clinical profile.
Measurements and BMI¶
The Measurements section gathers the basic body data:
Field |
Purpose |
|---|---|
Blood Type |
The resident’s blood type |
Height (cm) |
Height, entered once |
Weight (kg) |
Read-only — comes from the vital signs |
BMI |
Calculated automatically (weight / height²) |
Weight goes through the vital signs
The Weight field is not entered directly here: it picks up the last value recorded during a vital signs entry. Use the Enter Vital Signs button at the top of the record, or the small + next to the Weight field. The BMI then recalculates on its own as soon as height and weight are known.
Dependency (Katz)¶
The Dependency section shows, read-only, the summary of the resident’s dependency:
the current Katz category (O, A, B, C, Cd);
the validity end of the Katz assessment;
the active care plan, if there is one.
This information comes from the Katz assessment and the care plan; you do not edit it from the medical record.
The Katz category is declared, it does not set the amount
The category is used to declare the dependency profile to the health insurance fund. In the AViQ rates, the dependency allowance is the same amount for all categories (see The Katz assessment).
Clinical status¶
The Clinical Status section describes the resident’s functional autonomy. Each field offers a list of values:
Field |
Values |
|---|---|
Mobility |
Autonomous · Cane · Walker · Wheelchair · Bedridden |
Continence |
Continent · Occasional Incontinence · Frequent Incontinence · Incontinent |
Cognitive Status |
Normal · Mild Impairment · Moderate Impairment · Severe Impairment |
Communication |
Normal · Difficulty · Non-verbal · Aphasia |
Senses and risks¶
The Senses & Risk Assessment section completes the profile:
Field |
Values |
|---|---|
Vision |
Normal · Corrected (Glasses) · Impaired · Blind |
Hearing |
Normal · Hearing Aid · Impaired · Deaf |
Fall Risk |
Yes / No |
Pressure Sore Risk |
Low · Moderate · High |
These indicators guide daily monitoring and feed into the care plan.
Medical devices¶
The Medical Devices section lists the devices and permanent conditions:
Urinary Catheter (yes / no);
Stoma (yes / no);
Dental Status: Natural Teeth · Partial Denture · Full Denture · Edentulous.
Diagnoses (ICD-10 pathologies)¶
The Diagnoses / Pathologies section lists the resident’s pathologies, coded according to ICD-10 (International Classification of Diseases). Each line links the resident to a pathology from the catalog.
Column |
Purpose |
|---|---|
Pathology |
The pathology from the catalog (ICD-10 code) |
Category |
Taken from the catalog (circulatory, nervous, endocrine…) |
Severity |
Mild · Moderate · Severe — specific to this resident |
Status |
Active or Resolved |
Confirmed |
Clinically confirmed diagnosis (yes / no) |
Date |
Date of diagnosis |
Notes |
Clinical observations |
Severity and status specific to the resident
The catalog carries a default severity, but you set the severity and the status (Active / Resolved) for this resident. A Resolved status requires a resolution date. A given pathology can only be recorded once per resident.
Allergies¶
The Allergies section lists the allergies specific to the resident, linked to the allergen catalog.
Column |
Purpose |
|---|---|
Allergen |
The allergen from the catalog |
Category |
Drug · Food · Environmental · Contact · Insect/Venom |
Severity |
Low · Medium · High · Critical — specific to this resident |
Confirmed |
Clinically confirmed allergy (yes / no) |
Date |
Date identified |
Reaction |
Description of the reaction |
Drug allergens protect prescribing
For a drug allergen, the severity drives the behavior when prescribing: Critical blocks the prescription of the medication concerned; High, Medium or Low shows a warning. Food and environmental allergies are for documentation. See Prescriptions and medications.
An Additional Allergy Notes field lets you record, in free text, the allergies or remarks that are not in the structured list.
Medical contacts¶
The Medical Contacts section links the resident to their healthcare providers:
Specialist Doctors — one or more doctors (tags);
Reference Pharmacy.
The Attending Physician (the resident’s assigned doctor) is set instead on the resident’s general information. These contacts are reused elsewhere in Resthome (prescriptions, eHealth exchanges).
Advance directives and DNR¶
The Advance Directives section records the resident’s wishes:
Has Advance Directive (yes / no) — when ticked, a content field appears to describe what it contains;
DNR Order (Do Not Resuscitate) — the do-not-resuscitate decision.
The DNR is flagged everywhere in Resthome
As soon as DNR Order (Do Not Resuscitate) is ticked, Resthome makes it visible to care staff:
an orange banner “DNR — Do Not Resuscitate” at the top of the resident record;
a DNR badge on the kanban card and in the residents list;
a DNR filter in the search, to find the residents concerned.
Medical notes¶
Finally, a free-text Medical Notes field lets you record any important information that does not fit the structured sections.
Key points to remember¶
The medical record is the Medical Information tab of the resident record; it is reserved for care staff and logged (GDPR).
The weight comes from the vital signs (read-only) and the BMI is calculated automatically from height and weight.
The Katz category and the active care plan are shown there read-only; the category declares the profile, it does not set the allowance amount.
The diagnoses use ICD-10; severity and status (Active / Resolved) are specific to the resident.
Drug allergens protect prescribing: Critical blocks, the others warn.
The DNR triggers a banner, a kanban/list badge and a search filter.
Further reading¶
Prescriptions and medications — allergies and interactions when prescribing.
The Katz assessment — from dependency to category.