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Observations are structured checks recorded during each home visit. Unlike free-text notes, observations use a defined format (a photo, a yes/no answer, or a selection from a fixed list). This structured format makes it possible to track how a patient is doing over time - is the wound healing? Is the patient becoming more mobile? Are they eating on their own?

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The Four Observation Templates

The system has four pre-configured observation templates for home care. Each captures a specific aspect of the patient’s condition.

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1. Wound Photo

The wound photo is the most powerful monitoring tool for wound care patients. A photograph taken before and after each dressing change creates a visual timeline of healing. The care team and the supervising doctor can look back through the photo history to see whether the wound is getting smaller, cleaner, and healing well - or whether it is getting worse and needs a different treatment approach. Best practice: Take the photo before removing the old dressing (to show the wound environment) and again after the new dressing is applied (to confirm a clean, well-applied dressing). Attach both to the same observation record.

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2. Dressing Changed

Sometimes the nurse arrives and the dressing does not need to be changed yet (the wound is clean and the previous dressing is intact). Recording this as “No” is just as important as recording “Yes” - it shows the team that the nurse did assess the wound and made a clinical decision about the dressing.

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3. Feeding Ability

A change in this observation is clinically significant. If a patient who was self-feeding at the last visit is now needing assistance, the nurse should report this to the supervising doctor.

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4. Mobility Level

A patient who was walking with assistance at the last visit and is now bedridden is a concern that needs to be reported immediately. Declining mobility often signals a worsening of the underlying condition.

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How to Record an Observation

During a home visit:
  1. Go to Home Care workspace → Orders section → Observation → New
New Observation form showing patient name, observation template dropdown (Wound Photo / Dressing Changed / Feeding Ability / Mobility Level), practitioner, date, and the value entry section
  1. Fill in the details:
  1. Enter the value based on the observation type:
    • For Wound Photo: Click the attach button and upload the photo from your phone or tablet
    • For Dressing Changed: Select Yes or No
    • For Feeding Ability: Select Self Feeding, Assisted Feeding, or Tube Feeding
    • For Mobility Level: Select Independent, Needs Assistance, or Bedridden
  2. Add any extra notes in the free-text notes field if something unusual was observed.
  3. Click Submit.
The observation is now part of the patient’s permanent record and appears in their history timeline.

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Viewing a Patient’s Observation History

To see how a patient’s condition has changed over time:
  1. Go to the Patient History (Healthcare workspace → Records and History → Patient History)
  2. Search for the patient
  3. Look for Observation records in the timeline
  4. Compare the same observation type across different dates
For example, to track wound healing:
  • Find all “Wound Photo” observations
  • Open each one and view the photo
  • Compare photos from week 1, week 2, week 3, and week 4
This visual comparison is far more informative than written descriptions alone.
Patient history timeline showing multiple Wound Photo observations over four weeks with attached photos showing progression from a large open wound to a smaller healing wound

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Compiling a Diagnostic Report

If the doctor wants to compile multiple observations into a formal report (for example, to send to the patient’s GP or hospital), they can create a Diagnostic Report:
  1. Go to Home Care workspace → Orders section → Diagnostic Report → New
  2. Link to the patient
  3. Add the relevant Observations to the report
  4. Write an overall summary or impression
  5. Submit the report
The Diagnostic Report can be printed and sent to the referring doctor or shared with the patient through the portal.

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Field Guide: Observation

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Best Practices

  • Record observations at every relevant visit, not just when something has changed - a “no change” observation is still important information because it shows the team that the nurse looked and assessed the situation
  • For wound patients, always photograph the wound before removing the dressing, not just after - the state of the old dressing (soaked through, clean, stuck to the wound) tells the doctor important information about the wound’s behaviour
  • When recording Mobility Level or Feeding Ability, also add a note if you noticed anything that influenced the reading (e.g., “Mobility Level: Needs Assistance - patient says right knee is more painful today than last week”)
  • Never alter an observation after submission - if you recorded the wrong value, add a new observation with the correct value and a note explaining the correction

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Troubleshooting

I cannot attach a photo to the Wound Photo observation Make sure you are using a device with a camera or file access. The system supports image file uploads (JPG, PNG). If the file size is very large, reduce the photo resolution before uploading. The observation is not appearing in the patient’s history Check that the observation has been submitted. Draft observations do not appear in the history timeline. I recorded the wrong mobility level for a patient Do not try to edit a submitted observation. Instead, create a new observation with the correct value and add a note: “Correction to [date] observation - correct Mobility Level is [value].”
  • Nursing Care: Wound photo observations are typically taken alongside wound dressing procedures
  • Home Visit Record: Observations are linked to the visit encounter
  • Laboratory: Blood test results are a separate type of monitoring data