Capturing Clinical Notes

Capturing clinical notes

To access clinical notes:

1. Open the patient’s ‘Account Details’ page. The ‘Account Details’ page can be accessed from:
1. the Calendar by clicking on the patient’s name,
2. the ‘Search’ bar on the top right of the screen (click the icon), or
3. the ‘Accounts’ page by selecting a specific patient. 
2. Select the patient from the ‘Account Members’ section on the page.
3. Select the ‘Clinical Notes’ tab.

From this page you are able to:

• Capture ‘General Medical History’,
• Capture ‘Work / Hobbies’ information,
• Capture ‘General Progress Notes’,
• Capture new ‘Clinical Notes’, 
• View previous clinical notes,
• Edit clinical notes that have not yet been locked, and 
• Print and email clinical notes.

To capture general medical history, work and hobbies information, or general progress notes, click on the edit button on the top right of the relevant section. 

To view, print or email clinical notes, click on the 3 dots next to a specific note.

To add new clinical notes, click on the ‘add new’ button.

This will open the ‘Clinical Notes’ screen where you are able to complete an assessment on your patient.

Expanding the ‘Anatomical View’ will allow you to annotate on the diagrams.  Clicking on the body part you wish to make a note about, and dragging a line to where you would like to make the note, will cause a text box will then appear, allowing you to capture any notes.

The ‘Clear’ button will clear all annotations from the image.

The ‘Reset’ button will only clear new annotations that were made since the notes were opened.

The ‘Subjective’, ‘Objective’, ‘Assessment’, and ‘Plan’ sections can then be filled in as needed.

Should you wish to just save, and continue completing the notes later, click on ‘Save as draft’. This will allow you to edit your notes at a later stage.

To finish your note taking, click on ‘Save and lock’. This will complete your note taking for this encounter and lock the notes, preventing any further edits.

Once you have clicked ‘Save and lock’, the fields will become read only and the buttons at the bottom of the screen will change.

• ‘Capture invoice’ will open the capture invoice screen with the date of service and patient field pre-populated as per the clinical notes.
• ‘Copy and create new’ will open a new Clinical Notes window and copy all the fields from the clinical encounter with the new clinical note and applicable  date of service.
• ‘Email’ will open the ‘Email Clinical Notes’ screen with an editable template and automatic clinical note attached.
• ‘Print’ will open the clinical notes as a PDF for you to print. The PDF generated will contain the general progress notes as well as the clinical notes for the selected encounter.
  When printing clinical notes, the body diagrams will only be included in the document if annotations have been made on the diagrams.