Admissions: Progress Notes & Handover

Progress Notes are essential written records used in healthcare to document a patient's ongoing care, including their condition, treatment, and clinical developments. These notes support effective communication, continuity of care, and accurate tracking of a patient’s journey.

Handover occurs when the responsibility for a patient's care is transferred from one healthcare provider or team to another. It typically occurs during transitions of care, such as:

• provider to provider during shift changes,
• transfer between admitted care units,
• or when a patient is being discharged from one healthcare facility and admitted to another

The Handover template is using the ISOBAR format. This is a structured communication framework used in healthcare settings to facilitate effective handovers and transitions of patient care between healthcare providers. The ISOBAR handover method is designed to enhance patient safety, improve communication, and reduce the risk of medical errors during shift changes or patient transfers.

Contents:

1. Using the Progress Note Modal
2. Adding a Progress Note
3. Editing a Progress Note
4. Using the Handover Form
5. Adding Handover Notes

Progress Notes

Using the Progress Note Modal

The Progress Note modal can be expanded, collapsed, and moved around the screen. This allows you to minimise the window while viewing other information in the patient record without losing any notes you have recorded. You can also access the Progress Note modal for an admitted patient from the primary care side of the MediRecords Care app, so you may record Progress Notes from multiple locations.

You can minimise your current Progress Note using the Minimise icon in the top-right hand corner of the modal.

To maximise the window again, click the Maximise icon against the floating Progress Notes tool bar:

Adding a Progress Note

1. Navigate to the specific patient’s active Admission
2. Open the Admission tab, then hover over the Progress Notes quick action icon in the patient header to see the tooltip New Progress Notes, and click it to open the Progress Notes overlay.
   
    

3. Fill out the Progress Note Form:

   Type: Automatically pre-selected based on the user's category in their Profile.

   Clinical Type: This field is initially blank by default and offers only one available option: Diagnosis. Values provided in this field are provided by the most recent version of Snomed and are clinically coded.

   Clinical Options: This field is disabled until a Clinical Type is selected, and once active, it allows users to search and select multiple diagnoses based on the chosen Clinical Type.
   
   
    

4. After selecting Diagnosis as the Clinical Type, the Clinical Options field becomes active—search and select one or more diagnosis codes, then click Add to include them in the noteNote: The diagnosis will be displayed in this format within the note: <Date> - <Clinical Option>
   
   
    

5. Save the Progress Note. The Progress Note can only be saved after the Type field is filled out—click Save to complete the entry.

   Note: Diagnoses added from the Admission tab will also appear under Medical History and will be visible in both inpatient and outpatient contexts

   
    

6. All saved Progress Notes appear in the Admission Notes grid, alongside other documentation such as Forms and Handovers.
   
    
7. The Admission Notes view can adjusted to List View (pictured above), or Summary View (shown below), using the icons below the Admission Status.
   

Editing a Progress Note

MediRecords now allows users to edit Progress Notes created within a configurable time window—either 12 or 24 hours, depending on the tenant's lockout settings. If not explicitly configured, the default lockout period is 12 hours.

The Edit option is available in the grid (list) view of the Admissions module via the ellipses menu (⋯) next to the note:

1. Navigate to the Admissions module from the MediRecords main menu, ensure the patient is admitted, and select them from the admissions list to open their record.
   
    
2. Navigate to the Progress Notes section within the Admission tab, ensure you are in List View, locate the note you want to edit, and click the ellipses icon (⋯) to select Edit from the dropdown menu.
   
    
3. The original Progress Note will open in edit mode, allowing you to update the note as needed and click Save to apply the changes.
   
    
4. Once saved, the updated Progress Note will be stored and visible in both List View and Preview View.
   
   
   Note: Only Progress Notes can be edited—Handover and Admission Forms are excluded.
    

Handovers

Using the Handover Form

The Handover modal can be expanded, collapsed, and moved around the screen in the same way as the Progress Note modal. This allows you to minimise the window while viewing other information in the patient record without losing any notes you have recorded.

Adding Handover Notes

There are two methods for opening the Handover form:

A) From the Admissions grid, click the Ellipses icon in the Action column and select Handover:


 

B) From the Patient Header, click the Handover icon:

1. Open the Handover Form using either of the methods mentioned above.
    
2. Fill in the fields required:
   • Handover Type: Nursing, Medical, or Other
   • Handover Mode: Face to Face, Phone, Written Order, or Virtual
   • Attending Provider: Search and select from the user-list
   • Patient Status: Stable or Deteriorating
   • Subject: Enter your own, with a maximum character limit of 30
     
      
3. Input any required information into the writing area provided 
   
   
    
4. In the Received By field, select the Receiving Provider, and enter their password into the field provided. Click Verify.
   
   Notes: 
   If the password you have entered is incorrect, a message will be displayed beneath the Password field. 
   The Password is not a mandatory field, so if you do not want to use this, you do not have to to complete this workflow.
   
   
    
5. Click Handover to save the document.
   Note: Once a Handover document has been saved, you will be unable to edit it, so confirm you have the correct information entered first. 
   
    
6. Click Yes on the confirmation prompt if no further changes are needed.
    
7. The Handover document will then be visible under the Admission Notes tab. Clicking on the Handover will display the content in a preview window on the right.
   Note: All Handover documents are displayed in Admission Notes. Only the most recent saved Handover document is shown on the Admissions Grid.
   
   
    
8. Handover documents are visible from the Admissions Grid also, as a hyperlink against the patient's active Admission