Medical Records

This page explains how to use the Medical Dossier module to record, manage, and review medical examinations and observations for contacts in Dynamics Dossier.

Prerequisites

• The QTEAM Med. Dossier permission set must be assigned to your user account.
• Observation types and units must be configured. Run the Medical Dossier Setup codeunit to insert the standard set, or configure them manually via Medical Observation Types and Medical Observation Units.

Opening a Medical Dossier

Each contact has exactly one medical dossier. To open it:

1. Open the Dossier Card for the relevant contact.
2. In the action bar, select Medical Dossier.

Alternatively, access the dossier directly from the Contact Card using the Medical Dossier action added by the QTEAM Medical Dossier Contact page extension.

Dossier Status

Note: Setting Blocked to true prevents all further changes to the dossier, regardless of status.

Creating an Examination

An examination represents a single consultation or check-up session.

1. On the Medical Dossier Card, select New Examination in the action bar.
2. The Medical Examination Card opens with the contact pre-filled.
3. Set the following fields:

1. Save the record.

Recording Observations

Observations are structured clinical measurements linked to an examination or recorded independently.

From the Examination Card

1. Open the relevant Medical Examination Card.
2. In the Observations subpage, select New.
3. The Medical Observation card opens.

From the Dossier Card

The Observations subpage on the Dossier Card shows all observations for the contact across all examinations.

Filling in an Observation

Tip: If the observation type has Component Based set to true (e.g. Blood Pressure), enter the individual components (Systolic, Diastolic) in the Components subpage instead of using the Value field.

Component-Based Observations

For observation types where Is Component Based = true:

1. Open the observation record.
2. In the Components subpage, add a line for each measured value.
3. For each component, specify the LOINC Code, Display, Value, and Unit UCUM Code.

Example — Blood Pressure:

Observation Status Lifecycle

graph LR
    Registered --> Preliminary
    Preliminary --> Final
    Final --> Amended
    Amended --> Corrected
    Final --> Cancelled
    Preliminary --> Cancelled
    Registered --> EnteredInError["Entered-in-Error"]

Warning: Observations with status Entered-in-Error must not be used for clinical decisions.

Recording Medical Text Entries

Free-text clinical notes (Anamnesis, Physical Examination findings, etc.) are stored as Medical Text Entries.

1. On the Medical Dossier Card or Medical Examination Card, select Medical Texts.
2. The Medical Text Card opens, filtered to the current contact.
3. Select or create a text entry and choose the appropriate Text Type:

Setup

Observation Types

Observation types define what can be measured and how it maps to LOINC codes.

1. Search for Medical Observation Types.
2. Use New to add a custom type, or run the Medical Dossier Setup codeunit to insert the 14 standard types.

Key fields when creating an observation type:

Observation Units

Units use the UCUM standard for FHIR interoperability.

1. Search for Medical Observation Units.
2. Use New to add a unit, specifying the UCUM Code (e.g. mm[Hg]) and Display label.

Devices

If observations are collected via a measurement device, register it first:

1. Search for Medical Observation Devices.
2. Create a device record with its name, manufacturer, model, and serial number.
3. Optionally enter the FHIR Device ID for external system integration.
4. Set Active to ensure the device is available for selection on observations.

Reference Ranges

Reference ranges are used to determine whether an observation value is within normal limits.

1. Open the relevant Medical Observation Type record.
2. Add reference range lines with Gender, Age From, Age To, Low Value, and High Value.
3. Use Gender = Any for ranges that apply to all genders.
4. Set Age To = 999 when there is no upper age limit.

FHIR Integration

The Medical Dossier module is built for interoperability with external health information systems using HL7 FHIR. Observations and devices carry FHIR resource identifiers that enable round-trip data exchange with electronic patient dossiers (EPD), health information systems (HIS), and other connected platforms.

External system identifiers can be stored per observation to record the origin of imported data, including the source system URI and the identifier assigned by that system.

Note: FHIR integration configuration is performed by your implementation partner or system administrator.

See also: - Medical Dossier — Technical Reference - Absence Management - Managing Dossiers - Configuration