GileaM OneRecord EMR

Fictional product prototypeNo real patient data · Not for clinical use

Patient snapshot

BP146/92mmHg

Pulse88bpm

Temp38.1°C

SpO₂98% room air

Pharmacy

MarinaCare Pharmacy12 Ahmadu Bello Way · Victoria IslandPreferred · Verified · +234 700 627 4622

ePrescription connected

Active problems

Essential hypertensionSince 2022 · active
Recurrent malaria historyLast episode Jul 2026

Medications as of today

Amlodipine 5 mgOral · daily · patient reported
Ibuprofen 200 mgOral · as needed · OTC

Allergies

PenicillinHives · Severe · Confirmed

Immunizations

Record incompleteTetanus and seasonal influenza status need verification

Advance directive

Not on file

Ask the patient and document the directive, healthcare proxy, source and review date.

Care gaps

4 open

Vaccines · screening · medication reconciliation · lab review

Recent care

Malaria treatment14 Jul · Lagoon Clinic, LagosSource record available

Annual physical02 Feb · Accra Medical CentreCross-border summary

Before signing

2 open

Reconcile medications

Document neurological exam

STRUCTURED ENCOUNTER · DRAFT

General outpatient assessment

Marina East Hospital · Internal Medicine · 13 Aug 2026, 11:42

72% complete

ENCOUNTER WORKFLOW

Select the visit type

The selected workflow controls the required history, documentation prompts and completion rules.

NEW

Full history takingComplete chief complaint, HPI, ROS, medical, surgical, medication, allergy, personal, family, social, preventive and vaccination history.

VACCINATION HISTORY

Immunization status and source reconciliation

COVID-19Primary series reportedPatient reported · dates need verification

Tetanus-containing vaccineLast date unknownAge-appropriate review due

InfluenzaNot documented this seasonEligibility check required

Childhood / national scheduleRecord incompleteRegistry or patient-held card not connected

CLICK-TO-DOCUMENT

Chief complaint option library

Select every symptom or reason for visit that the patient reports.

38 options

General0 selected

Pain0 selected

Cardiorespiratory0 selected

Other common reasons0 selected

Chief complaint

Primary reason for today’s encounter, in the patient’s own words

3 selected

Chief complaint statement Required

Presenting symptoms · select all that apply

Encounter typePatient priority

History of present illness (HPI)

Narrative plus structured OPQRST symptom characterization

8 fields

Review of systems (ROS)

Document positives, explicit negatives and systems not reviewed

14 systems

Past medical history & past surgical history

Diagnoses, hospitalizations, operations, procedures, anaesthesia and transfusions

3 to confirm

Medications

Prescription, OTC, supplements, traditional medicines and recently completed treatments

Review

Medication allergies

Drug ingredient, class, reaction, severity, onset, certainty and source

1 severe

Other allergies & intolerances

Food, environmental, latex, adhesive, contrast and non-allergic intolerances

Unverified

Personal history

Daily life, function, occupation, diet, activity, sleep and reproductive context

Review

Family history

Relationship, condition, age of onset, living status and source

3 entries

Social history

Substance exposure, living conditions, safety, access barriers and infectious risk

6 domains

Amina Okafor

General outpatient assessment

Select the visit type

Immunization status and source reconciliation

Chief complaint

History of present illness (HPI)

Review of systems (ROS)

Past medical history & past surgical history

Medications

Medication allergies

Other allergies & intolerances

Personal history

Family history

Social history