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Observations

The Observations section sits between Detailed Examination and Social History. It holds sets — each one a timestamped, labelled collection of vital signs, added as many times as the call needs.

The rule this feature runs on​

A parameter that was not recorded is absent, never defaulted. It is not printed, it is not assumed normal, it is not assumed abnormal, and the AI tools are told in as many words that they must not assume either.

This is why there are no pre-filled values anywhere in the entry form, and why an incomplete set produces no NEWS2 score.

Adding a set​

Tap to add a set and the entry modal opens, grouped by how you enter things rather than by body system — so the on-screen keyboard opens once instead of thrashing up and down the form.

The typed block​

Time and label first, then, on a shared grid so the columns line up:

  • Respiratory rate
  • SpO₂
  • Heart rate
  • Blood pressure
  • Temperature
  • Blood glucose
  • EtCO₂
  • Capillary refill

Quick values appear under a numeric field only while it has focus — tap one instead of typing. Tap it again to clear it, so an accidental tap always returns to "not recorded".

Blood pressure deliberately offers no quick values. A guessed systolic or diastolic is more likely to mislead than to help. It does auto-format: six digits become 120/80, and typing an explicit / lets you enter a two-digit systolic.

The tap block​

Below the typed fields, entered entirely by tapping:

  • Oxygen delivery — Air or Supplemental O₂. A flow-rate field appears only when supplemental is selected.
  • ACVPU — Alert, Confusion, Voice, Pain, Unresponsive
  • GCS — scored by component
  • Pain — 0 to 10
  • Pupils — with a pick list
  • Rhythm — with a pick list

Pupils, rhythm and the set label all support custom options, so the descriptors your service uses can be added once.

GCS in an observation set​

GCS is scored by component, never entered as a remembered total. Each chip shows the number large with its descriptor underneath, because the descriptor is what tells M5 from M4 under pressure.

There is no total until all three components are set:

  • Complete: GCS 15/15 (E4 V5 M6)
  • Partial: GCS E4 M5 — components printed, no invented sum

Oxygen flow rate​

The flow field appears only while delivery is set to supplemental. If you type a value and then change delivery to air, the value is not deleted — it simply stops being printed. Silently discarding something you typed would be worse than carrying it unseen.

Flow rate is documentation only. It rides along with the SpO₂ reading in the printed text but plays no part in the NEWS2 score, which looks only at whether delivery is air or supplemental.

EtCO₂ units​

Your preferred unit — kPa or mmHg — is a setting (Settings → General, default kPa). It is stamped onto each set when the set is created, so changing the preference later never reinterprets a reading you already took. Tap the field to see the value in the other unit.

The include-in-report toggle​

Each set has an eye toggle governing whether it appears in the ePRF text only.

DestinationRespects the toggle?
The generated report / ePRF textYes
Reflective practice PDFNo — every set is included
AI toolsNo — every set is included

The reasoning: the toggle exists to control what you paste into a trust system, not to hide observations from your own reflective record or from a tool reasoning about the patient.

Tapping a set card anywhere reopens it for editing. The eye is the one exception — it toggles inclusion without opening the set.

How observations appear in the report​

Each committed set produces one line in the report's standard Label - content shape:

Obs (14:32 On arrival) - RR 22, SpO2 94% on air, HR 108, BP 138/84, Temp 37.4, ACVPU A, NEWS2 5

What is deliberately absent​

There is no free-text note field on an observation set. Observations are measurement. Anything narrative belongs in the section free text, where it will read as narrative rather than as a recorded value.

See also​

  • NEWS2 — how the score is derived and why it sometimes does not appear
  • ATMIST pre-alert — seeds its vitals from your most recent set