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Patient Watch

Smart Health’s Patient Watch clinical information system supports the management of patients and their data by Tele-care Guides and Health Coaches.  It consists of two interoperating components:

  • Smart Health, which provides the user interface and management of electronic medical records

  • PaJR, which analysis patient responses to questionnaires and identifies Issues that require intervention by Health Coaches.


Features include:

  • Integration with health service information management systems (e.g. patient administration system (PAS), diagnostic results, electronic/scanned medical record (EMR/SMR)

  • Execution and capture of call based questionnaires by Tele-care Guides

  • Assignment of Issues identified by questionnaires to Problem and Action records by Health Coaches

  • Bulk import of new patients to the Patient Watch program

  • Patient list views

  • Saving of patient lists to .csv files

  • Sending a letter to a patient's GP

Patient Status Records:

  • Each patient who is actively receiving calls and completing questionnaires must have accurate and up to date:

    • Treatment Status record, including assigned Tele-care Guide, Health Coach and at least one questionnaire schedule

    • Health Journey Check Status record, including Participation Status that is one of the five values between Candidate and VIP inclusive


Patient Lists

  • View patients using the Patient List view, for which:

  • The Issues and Problems tab (for Health Coaches) lists Patients with unresolved Issues and High Priority Problems and Actions

  • The Patient Watch Calls tab (for Tele-care Guides) list patients with calls/questionnaires that are due

  • The Patient List views can be sorted on other columns

  • To export the Issues and Problems Patient List for all of your patients to a .csv file:

    • Select Health Coach (if you want the list for another Health Coach)

    • Check the All Patients check box

    • From the Main Menu, select File/Save CSV

    • In the dialog box, select Patient List (All Patients in Medical Group option can only be run after 6pm) and click OK

    • Save the .csv file to your preferred location


Questionnaires (Tele-care Guide)

  • When viewing the Patient Summary, click the Initiate Call button to launch a questionnaire

  • Complete the Respondent and Location fields on the questionnaire Call tab

  • Complete the mandatory fields on the Questionnaire tab, recording the patient's responses

  • When all mandatory fields are complete, click the Submit Questionnaire button to send the questionnaire responses to PaJR

  • Review the Issues that are returned from PaJR (Issues tab), update Questionnaire tab responses and click Submit Questionnaire again if needed

  • Complete the remaining fields on the Call tab and Save the Questionnaire (Final)


Problem and Action (Health Coach)

  • Open a Questionnaire and select the Issues tab

  • Right click on an Issue, select Resolve Issue from the context menu and then:

  • Click the No further action button if no follow up action is required

  • Click Link to Problem and Action to link this record to an existing Problem and Action record (existing Problem and Action records are listed in the dialog box)

  • Click Create Problem and Action to create a new Problem and Action record

Other elements of the Patient Watch system:

  • Patient demographic data is maintained in the local health service PAS, from where it is automatically imported into Smart Health

  • Smart Health may also support other clinical programs at your health service, which will result in other types of clinical records also appearing in Patient Watch patient histories

  • When Patient Watch clinical records are saved, they are automatically copied to your health service’s scanned medical record (SMR) or electronic medical record (EMR).


If you have further questions about this system, please talk to your Patient Watch supervisor.
Patient Watch
Patient Summary
Patient Summary

If the patient has one or more Patient Watch clinical records, you can select Patient Watch from the Programs node in the Navigation tree to view:

  • Patient Watch Summary

  • The list of clinical records for that patient


If the patient is new to the Patent Watch program, the Patient Watch Program entry and Summary view will be created after the first clinical record for that patient has been saved.

The Patient Watch Summary is a read-only view of key data for the patient.  Click the links beside these fields to open the service records in which the data was recorded.

The service record history is a chronologically ordered list of service records for that patient.  Double click records in the service record history to open them.

Patient List
Patient List

In the Provider section of the navigation tree, select Patient List to see patients who have:

  • Unresolved Issues and High priority Problems and Actions (Health Coach focus)

  • Upcoming Calls/Questionnaires (Tele-care Guide focus)


The Patient Lists display a Tele-care Guide’s or Health Coach’s patients. The list view can be sorted by any of its columns.

  • The Calls list displays the logged-in Tele-care Guide’s patients in the order of their next phone call

  • The Issues and Problems List displays the logged in Health Coach’s patients in the order of those with the most high priority Problems


In both Patient List views, other Tele-care Guides and Health Coaches can be selected, including options to display the patients of all Health Coaches.


Click on column headings to sort the list according to that column.


Double click a patient to open the patient.

On the Issues and Problems tab, check the All Patients check box to list all patients, irrespective of how many high priority problems they have.  To save this list to a .csv file, select File/Save CSV from the main menu, then select Patient List and click OK.

  • Note: There is a limit of 100 patients to export the list to a .csv file.

Treatment Status
Treatment Status and Health Journey Check Status

Treatment Status


Treatment Status records are used to record key fields that affect how patients are managed within the program.

A new Treatment Status record is usually created whenever there is a change in a patient’s treatment status.  The new Treatment Status record is automatically populated with data from the previous Treatment Status record, so that users only need to change a small number of fields.

There are several fields that must be completed before patients are displayed in Patient List views and are ready to receive phone calls.

  • Participation status

  • Tele-care Guide

  • Health Coach

  • For each Questionnaire that the patient is scheduled to receive:

    • Suspend calls

    • Call frequency

    • From

    • Phone

    • Call window

    • Respondent


Health Journey Check Status

Health Journey Check Status records are used to record key fields that affect how patients are managed in relation to the delivery of Health Journey Check Questionnaires and the management of associated Problems and Actions.

A Health Journey Check Status record is usually created whenever there is a change in a patient’s status for Health Jourey Check Questionnaires.  The new Health Journey Check Status record is automatically populated with data from the previous record, so that users only need to change a small number of fields.

The following fields must be completed before patients are displayed in Patient List views and are ready to receive phone calls.

  • Participation status


When all of the fields that are needed to begin calling and managing patients have been completed and these two records, the Initiate Call button at the bottom of the Patient Summary will be enabled when the next call for that patient is due.

Call Questionnaire

When a Tele-Care Guide is ready to call a patient (for example, when the patient is next on the Tele-Care Guide’s Patient List), click the Initiate Call button on the Patient Summary (or select New Service/Patient Watch/Questionnaire from the Main Menu).

Smart Health will open a new Questionnaire record, ready for the call.

Call Tab (Start of call)

  • Select Respondent (mandatory field)

  • Select Location (mandatory field)


The selection of Respondent (Patient or Caregiver) enables the relevant questions in the Questionnaire Tab

Questionnaire Tab

  • Work through the questions with the Patient or Caregiver, taking care to complete all of the mandatory (yellow) fields

  • The last question on this tab is about your evaluation of the respondent, and is also mandatory

  • When you have completed all the questions, Submit the Questionnaire response to PaJR by clicking the Submit Questionnaire button (if the button is not enabled, not all of the mandatory questions and fields have been completed)

  • If PaJR detects any Issues from the Questionnaire Responses, it will return a list of those Issues, which will be displayed on the Issues Tab ()

  • You can review the Issues, update the Questionnaire and re-submit the responses to PaJR if needed.

Issues Tab

  • Review the Issues returned by PaJR to ensure that they are consistent with your understanding of the patient’s or caregiver’s responses that you recorded in the questionnaire

  • The Issues table can be sorted by each of its columns

  • Issues have a Timeframe that is determined from an Urgency sent by PaJR.The list of Timeframes, in order of importance, is:

    • STAT

    • 3 hours

    • 24 hours

    • 3 days

    • 7 days


Call Tab (End of call)

  • When the Questionnaire and Issues are finalised, complete the remaining fields on the Call Tab

  • Save the Call/Questionnaire record


The Call/Questionnaire record can be saved as a draft (Save Draft) at any time, for example if the call is interrupted.

Problem and Action
Problem and Action

Problem and Action records are used by Health Coaches to record details of Patient Problems, including the PaJR Issues that alerted the Watch program to the Problem, various Problem parameters and the Actions that are created to address the Problem.

Problem and Action records are created by:

  • Assigning Issues in Call/Questionnaire records that have been completed and saved by Tele-Care Guides.

  • Open Call/Questionnaire record

  • Select the Issues Tab

  • Right click an Issue and select Resolve Issue

  • Select an existing Problem and Action record from the list, or, create a new Problem and Action record, or, record No further action for this Issue.

  • New Service/Patient Watch/Problem and Action in the Main Menu.


Complete the fields in the Problem and Action record as appropriate to the care being provided to the patient.

GP Letter
GP Letter

You can create a letter for your patient’s GP:

  • Select New Service/Letter from the Main Menu

  • Select the appropriate Letter template (Patient Watch GP Letter) and click OK

  • The selected letter template will open

  • If the patient’s GP has been entered on the Patient Details/Providers and Consents Tab (), the Recipients table will have a row for “To” with the GP details.If the To Recipient does not show the GP because the GP has not been completed in Providers and Consents, the GP can be entered into the Template.If you update the GP in Providers and Consents after selecting a Letter template, you will need to Cancel it and select the Letter template again.

  • You can add other Recipients (as CC)

  • Select the format for the salutation

  • Copy and paste the appropriate letter text into the one or more of the three text fields (Opening text, Report and Closing text)

  • Select any items that you would like included in the letter

  • Select whether you would like the patient’s Patient Watch Summary to be attached to the Letter

  • Click Save (the letter can be saved as a draft at any time).


When the Letter is Saved (final):

  • The letter is rendered as an appropriately formatted pdf document

  • The pdf letter can be opened by clicking the Open PDF button at the bottom of the form

  • The letter is sent to the patient’s GP electronically if the GP’s practice subscribes to your health service’s secure messaging system

  • If the GP’s practice does not subscribe to the health service’s secure messaging system, the letter is queued for printing

  • You can manage the print queue by selecting Reports/Print Queued Correspondence from the Main Menu

  • The Letter service record displays the status of each Recipient in the table at the top of the form (Sent, delivered and read for secure messaging recipients and Queued for printing for other practices):

Export Patient List
Export Patient List

Lists of patients with unresolved Issues and high priority Problems and Actions can be exported for analysis and reporting.

  • Select Patient List/Issues and Problems tab

  • Select the All Patients check box to list all patients, regardless of how many unresolved Issues or high priority Problems and Actions they have

  • Select File/Save CSV from the main menu

  • Select Patient List (displayed patient list) or All patients in medical group (this option can only be run after 6pm)

  • Click OK

  • Select the destination for the .csv file to be saved.

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