Clinical -Today's Notes

Clinical - Today's Notes

In this article, you will learn how to add progress notes to a patient's record. 

Information entered in Today's Notes can relate to the current, most recent or historical consultations. 
Remember to change the date and time of the consultation if the notes you are entering relate to a past or historical consultation.

To change the date and time, click the Date above the progress notes to reveal a drop-down calendar.



To change the time, click the Time above the progress notes to reveal a drop-down list of times.



Today's notes are structured as a  subjective, objective, assessment, and plan (SOAP) document. Information captured and recorded from the various widgets are sorted based on the SOAP standard irrespective of where the cursor is placed in the notes. The order of the notes is as follows:

• Reason for visit
• Observations
• Examinations
• Clinical Drawings
• Clinical Templates
• Pathology Requests
• Radiology Requests
• Diagnosis
• Prescription
• Immunisations
• Procedures
• Extended Care
• Patient Education 

There are multiple ways to add progress notes about the consultation. You can use Free Text, Reasons, Observations, Examinations, Procedures, Clinical Drawings or Diagnoses. In this tutorial, you will learn how to enter progress notes using each of these methods.



Free Text

There is a tool bar at the top of the progress notes for formatting the text. The tool bar contains text formatting tools and shortcut options for entering free text into progress notes. You can align text to either the left or right, or the centre of the screen, use bullet-points and numbered lists, indent text, insert hyperlinks and tables, and use the shortcuts to insert common medical terms into the progress notes.



The first section of the tool bar (Format) allows you to easily switch between a number of predefined text formats. Click Format to reveal the list of available text formats, and then click to select the Font.


To change the font to either Bold, Italic or Underline, click the corresponding icon on the tool bar.



To align the text Left, Right, Centre or Justify (edge to edge), click the corresponding icon on the tool bar.



To insert Bullet Points, Numbered Lists or Indent Text, click the corresponding icon on the tool bar.



To insert a Hyperlink, click the corresponding icon on the tool bar.



To insert a Table, click the corresponding icon on the tool bar.



Reasons

To add a detailed reason for the visit into the progress notes, using correct medical terminology, conditions and severity, you can look up the condition in the database. Click Reason to open the reason for visit form.



Click the Search Field to look up the medical condition.



Type the First Few Letters in the search field to reveal a drop-down list of the closest matches. Click to select the Condition.

If you cannot find the reason you are looking for, just type in the name of the patient's condition or symptoms. You do not need to make a selection from the list.



Complete the rest of the form with all the required details, and click Save.

Add to PMH stands for Add to Personal Medical History. If you tick this box, the condition will be added to the Medical History in the patient's record.



The reason will automatically be added to the progress notes.

To add another or multiple reasons for visit, follow the same process and the system will add the additional reasons to the progress notes. There is no limit to the number of reasons that can be added to the progress notes.

Observations

To add an observation into the progress notes, like recording the patient's vitals click Observation and select and observation form.



The below example uses the Vitals observation form.  

*Note: If you require a custom clinical template, you can contact MediRecords Support Team (support@medirecords.com) to request one.

Complete the observation form with all the required details, and click Save.



The observation will automatically be added to the progress notes.

The observation will also be saved to Observations in the patient's record.

To add another or multiple observations, follow the same process and the system will add the additional observations to the progress notes. There is no limit to the number of observations that can be added to the progress notes.

To add an observation into the progress notes, like recording the patient pediatric vitals click Observation and select and observation form.

The below example uses the Peadiatric Vitals observation form.  

*Note: If you require a custom clinical template, you can contact MediRecords Support Team (support@medirecords.com) to request one.

Complete the observation form with all the required details, and click Save.

The observation will automatically be added to the progress notes.

To add another or multiple observations, follow the same process and the system will add the additional observations to the progress notes. There is no limit to the number of observations that can be added to the progress notes.

Examinations

To add an examination to the progress notes, click Examination and select a clinical examination template.



The below example uses the General Examination examination form.  

*Note: If you require a custom clinical template, you can contact the MediRecords Support Team (support@medirecords.com) to request one.

Complete the form with all the required details, and click Save.



The examination will automatically be added to the progress notes.

To add another or multiple examinations, follow the same process and the system will add the additional examinations to the progress notes. There is no limit to the number of examinations that can be added to the progress notes.

Procedures

To add a procedure to the progress notes, click Procedure to open the procedure form.



Complete the form with all the required details, and click Save.

The procedure will automatically be added to the progress notes.

To add another or multiple procedures, follow the same process and the system will add the additional procedures to the progress notes. There is no limit to the number of procedures that can be added to the progress notes.  

Clinical Drawings

To add a clinical drawing to the progress notes, click Drawer to open the clinical drawer.



Select the Category & Type, add visual imagery to drawing using the Tools & Colours, type any relevant Comments and click Save.

To upload your own image into the clinical drawer, click Upload Image. Uploaded images should be no larger than 1MB in size, and the preferred image size is 550px wide, by 450px high.



The clinical drawing will automatically be added to the progress notes.



The drawing will also be saved to the Clinical Drawings in the patient's record.

To add another or multiple clinical drawings, follow the same process and the system will add the additional drawings to the progress notes. There is no limit to the number of drawings that can be added to the progress notes.

Diagnosis

To add a detailed diagnosis to the progress notes, using correct medical terminology, conditions and severity, you can look up the condition in the database. Click Diagnosis to open the diagnosis form.



Click the Search Field to look up the medical condition.



Type the First Few Letters in the search to reveal a drop-down list of the closest matches. Click to select the Condition.

If you cannot find the diagnosis you are looking for, just type in the name of the patient's condition or symptoms. You do not need to make a selection from the list.



Complete the rest of the form with all the required details, and click Save.

*Note: Add to PMH stands for Add to Personal Medical History. If you tick this box, the condition will be added to the Medical History in the patient's record.

The diagnosis will automatically be added to the progress notes.



To add another or multiple diagnoses, follow the same process and the system will add the additional diagnosis to the progress notes. There is no limit to the number of diagnoses that can be added to the progress notes.

This concludes part four of the Clinical Tutorial.