Adding a Clinical Note

Adding a Clinical Note

1. In the Patient Record > Clinical Notes, click New.
2. Click into the Text area and type your notes.
3. You can add attachments, insert templates and format the text using the using the Text Editor - for a more detailed explanation of how the Text Editor works see section Using the Text Editor.  
4. Clinical Note Category: You are able to categorise your Clinical Notes (optional).
   1. Select a Clinical Note Category from the pick list.
   2. If the list if empty, your system administrator contact your system administrator to add categories.
5. Case: If you use the Case Management module, and the patient has an active Case, you can associate the clinical note with a Case.
6. You can read Recent Clinical Notes at the bottom of the screen (scroll down the page).
7. Saving your Clinical Note:
   1. Save Draft: If you want to keep the note as a draft and come back to it later click Save Draft.
   2. Save Approved: To save the note as a final, click Save Approved.

Draft Notes

Draft notes have "DRAFT" printing across their background. While a note is in a Draft state, previous versions are not saved if it is edited.  

Only when the draft  state is removed will the Clinical Note be considered final and from that point onwards, any changes made to it will be recorded as different versions.

Making a Clinical Note final is simple:

1. Click Edit
2. Scroll down and untick the Draft box
3. Click Update Clinical Note