---
title: "Understanding the Patient File"
url: "https://help.healthbridgeclinical.co.za/en/article/understanding-the-patient-file"
language: "en"
last_updated: "2026-08-05T09:41:30.650Z"
---

# Understanding the Patient File

## Understanding the Patient File

**What:** Every patient file is organised into a left-hand menu of sections, Overview & timeline, Account & medical aid, General screening, Conditions & medication, Lifestyle & family, Surgical & hospitalisation, Allergies, Vitals & metrics (or the age/sex-specific equivalents below), and Vaccination schedule.

**Why:** Knowing where each piece of information lives means you spend less time hunting during a consultation and more time with the patient.

**When:** Any time you open a patient's file, this menu is always available in the same place, whether you're preparing for a consult or reviewing history afterwards.

## Sections

Shown below on Anaya Nkosi, a 12-year-old patient, her file happens to display every age/sex-specific section variant (Growth charts, Developmental screening, Gynae) alongside the standard ones, so one patient demonstrates almost the entire menu.

## 1\. Overview & timeline

*Location: Patient file › left menu (default section)*

The default view when you open a patient's file. It gives you a quick summary at a glance: patient details, current **Conditions & Medications**, a **Lifestyle/Family Hx** summary, **Surgical & Hospital Hx**, linked **Family members**, and the full **Patient timeline** below, every note, pathology result, and uploaded document, in order.

![Overview and timeline section showing patient details, conditions and medications, family members, and surgical and hospital history](https://cdn-assets.productfruits.com/25b66956-2a46-4ead-9c5b-4d56d6e59740)

## 2\. Account & medical aid

*Location: Patient file › left menu*

The patient's demographic and billing details: contact information, medical aid scheme and membership number, and the **Patient liable amount**, any outstanding balance owed by the patient or account holder.

![Account and medical aid section showing patient liable amount, last benefit check result, patient details, and medical aid detail fields](https://cdn-assets.productfruits.com/1fcfc627-d847-48ae-87b0-8b793076ff0c)

## 3\. General screening

*Location: Patient file › left menu*

A year-by-year grid of screening tests, blood glucose, cholesterol, colonoscopy, and more, so you can see results and trends over time at a glance. Click the **+** at the end of a row to add a result for that test. If the test you need isn't listed, click **'+ Add'** to select it, or add a fully custom test/metric to track.

![General Screening section showing a year-by-year grid of tests including HbA1c, Triglycerides, Creatinine, and Urea with recorded results](https://cdn-assets.productfruits.com/4bc2ce35-d779-4dbe-83e6-e30a801868c9)

## 4\. Conditions & medication

*Location: Patient file › left menu*

Any recorded allergies appear as a red banner at the top of this page. Below it:

-   **Chronic conditions**, diagnosed conditions, with linked medication, an ICD-10 code, and a toggle to flag the condition as chronic or a Prescribed Minimum Benefit (PMB) with the patient's medical aid.

-   **Previous conditions**, earlier conditions still relevant to current treatment.

-   **Other medication**, acute medication or supplements, also taggable as chronic/PMB.

-   **Discontinued**, any medication marked as discontinued from the sections above.

![Conditions and medication section showing the red allergies banner, Diabetes Type 2 and Hyperlipidaemia conditions with linked medications](https://cdn-assets.productfruits.com/3d09e633-e7e1-4cb0-815b-b2e730c982df)

## 5\. Lifestyle & family

*Location: Patient file › left menu*

Two sub-tabs: **'Lifestyle'** covers smoking, alcohol, recreational drug use, stress, activity level, and diet. **'Family History'** lists heritable conditions with Mother/Father tags per disease. For patients 12 and younger, this section also includes birth details.

![Lifestyle and family history section showing the Lifestyle sub-tab with smoking and alcohol details](https://cdn-assets.productfruits.com/0fa97156-2db6-4e14-bf1d-e6f240f98881)

## 6\. Surgical & hospitalisation

*Location: Patient file › left menu*

Lists any surgical procedures and hospital admissions on record. Toggle **'No surgical or hospitalisation history'** if none apply, or click **'Add surgery'** to record one.

![Surgical and hospitalisation section with the Add surgery button and hospitalisation history notes](https://cdn-assets.productfruits.com/530c5606-29ba-4f16-a2a3-38a40976bbdb)

## 7\. Allergies

*Location: Patient file › left menu*

Broken into **Medication**, **Non-Medication**, and **Food** allergies. Toggle on any that apply and set a severity of **Severe**, **Moderate**, or **Mild**. Anything recorded here surfaces automatically as a warning banner elsewhere, for example on the Medicine tab and printed prescriptions.

![Allergies section showing Penicillin toggled on as Severe under Medication, and Shellfish toggled on as Moderate under Food](https://cdn-assets.productfruits.com/b90e6744-f416-47ec-b963-fb4471cf2d87)

## 8\. Vitals & metrics *(adult patients)*

*Location: Patient file › left menu*

Record and track vital statistics, blood pressure, weight, BMI, waist circumference, and more, plus HIV-related metrics where relevant. Switch to the **'Charts'** sub-tab to see each metric graphed over time.

![Vitals and metrics section showing General vitals fields (Temperature, Pulse rate, Blood pressure) and HIV metrics fields, on an adult patient](https://cdn-assets.productfruits.com/b06a691b-4b08-4e8c-8d13-5b781e8f01db)

> **Age-specific:** For younger patients, this menu item is replaced by **'Growth charts & metrics'** below, and a separate **'Developmental screening'** section also appears.

## 9\. Growth charts & metrics *(younger patients)*

*Location: Patient file › left menu*

The same vitals fields as the adult version, plus two paediatric-specific fields: **Head circumference** and **MUAC** (mid-upper arm circumference, used to screen for malnutrition). The **'Charts'** sub-tab plots each metric against standard growth curves for the patient's age.

![Growth charts and metrics section on a 12-year-old patient, showing General, HIV, and MUAC field groups](https://cdn-assets.productfruits.com/855d6f2d-8f0b-4df9-8291-039af8d02afb)

## 10\. Developmental screening *(younger patients)*

*Location: Patient file › left menu*

A milestone checklist by age (Birth through 5-6 years). Toggle **'Activate Developmental Screening'** on, then tick **'All Achieved'** for each age band as milestones are confirmed. Overdue bands are flagged automatically.

![Developmental Screening section showing age bands from Birth to 5-6 years with All Achieved checkboxes and overdue flags](https://cdn-assets.productfruits.com/f6b2f0d7-2057-47e3-9418-8c31b67c13c4)

## 11\. Vaccination schedule

*Location: Patient file › left menu*

Toggle **'Opt-out of Vaccination Schedule'** if it doesn't apply to this patient. Otherwise the schedule tracks each age band, flags overdue vaccinations, and lets you tick **'Up to date'** once given. Use the download, email, and print icons at the top to share the schedule, or **'Add custom vaccination'** for one outside the standard schedule.

![Vaccination Schedule section showing age bands from Birth to 12 Years with overdue flags and Up to date checkboxes](https://cdn-assets.productfruits.com/edd701ab-cf5f-4dd2-a762-b824d7dd7630)

## 12\. Gynae *(female patients)*

*Location: Patient file › left menu*

A template for recording women's health information: **Contraception** in use, **Pregnancies** and any **Pregnancy complications**, and **Menstrual history**.

![Gynae section showing Contraception, Pregnancies, Pregnancy complications, and Menstrual history fields](https://cdn-assets.productfruits.com/8ca64856-3f72-4dec-a3a5-87d8f0520615)

## Frequently asked

**Q: Why do I see 'Growth charts & metrics' and 'Developmental screening' instead of 'Vitals & metrics'?**

Healthbridge Clinical tailors the patient file menu to the patient's age. Younger patients see growth-tracking and developmental screening sections in place of the standard adult vitals section.

**Q: Why does 'Gynae' appear for some patients and not others?**

The menu is tailored to sex as well as age. Female patients get the additional 'Gynae' section for recording contraception, pregnancy, and menstrual history; male patients don't see it at all.

**Q: Where do I add a screening test that isn't already listed?**

On the General screening section, click '+ Add' to select a test that isn't shown by default, or add a fully custom test or metric you'd like to track for that patient.

**Q: How do I discontinue a medication?**

On the Conditions & medication section, use the discontinue action next to the medication line item. It then moves into the 'Discontinued' section for that patient.