CareRight's Clinical Note system is designed with the principles of National Safety and Quality Health Service (NSQHS) Standards - Action 1.16
The capabilities have a focus on:
- Maintaining accurate, auditable clinical records
- Allowing correction of errors without loss of prior information
However, Careright is a system with multiple configuration options.
It is your organisation's responsibility to design compliant policies, processes and procedures around the management of clinical notes.
Clinical Note Categories
In System Administration > Patient Settings > Clinical Note Categories; categories can be configured.
This functionality allows certain categories to be made available, on a location or group basis.
For example; it is common for mental health organisations to employ both regular Clinical staff, and Clinical Psychologists who have extensive privacy requirements.
For scenarios like this; we recommend:
- Creating a clinical note category for individual providers; ie Dr Smith Private Notes; limited to a specific location.
- Creating more general clinical notes, such as "Observation", "Consultation Note".
Privacy
Where a clinical note category is limited to a location, only staff in that location with viewing permissions can see that note.
Related
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Clinical Notes
All your clinical notes can be stored against a patient and are fully reportable. This removes the need to hand write notes and allows other staff members (where appropriate) to see notes you have written in real time.
Filtering Existing Clinical Notes
From the main Clinical Notes page, you are able to filter the notes that appear on the screen. The following filters are available:
Filter | Description | Example |
Discipline | Only display notes added by a specific discipline of staff. This can be configured via Admin > Staff Member Types and is automatically added as each note is created. | Psychiatrists |
User | Only display notes added by a specific user | Joe Bloggs |
From | Only display notes added on or after a specific date and time | 01/01/2015 00:00 |
To | Only display notes added on or before a specific date and time | 31/01/2015 23:59 |
Case | Only display notes related to a specific Case * | Alcohol Addiction |
Searching Through Clinical Notes
To do a more specific search of all Clinical Notes, use the Patient search on the Patient Record → Summary page.
Adding a Clinical Note
See main article: Adding a Clinical Note.
Approving a Clinical Note
A Clinical Note can be approved by a user with the correct rights. Notes that are available for Approval have the Approve button on the right of them. Simply click Approve and then confirm that you want to proceed.
This feature may have been disabled in your system - contact your system administrator if you are unsure.
Editing a Clinical Note
See main article: Editing a Clinical Note
Striking a Clinical Note
See main article: Strike a Clinical Note
Reporting
Clinical Notes are available in Datasets.
