Clinical Notes

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

See

• Edit a Clinical Note Category
• Delete a Clinical Note Category

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:

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.

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

To maintain a full longitudinal record and to ensure that there is always an audit trail of changes made, each version of a clinical note is stored and viewable.

To view Versions of a clinical note:

1. Locate the Clinical Note (see Clinical Notes to learn how to filter or search).
2. Click Show.
3. If more than one version exists, then the Versions button will appear - click Versions.
4. The latest version will display, you can cycle through versions using the Previous or Next buttons.

Information stored for each version includes:

• Create date and time
• Update Date and time
• Signature - who added the note
• Approval date and time
• Approver Signature - Who Approved the note
• The contents of the note
• If the note was a draft.

When can I edit a clinical note?

Prior to a note being approved; a clinical note can be edited if:

• You have note creation rights
• Or you have note approver rights

After a note is approved, you can edit the note if

• You have the can edit approved clinical notes permission. This is designed for an administrator or compliance role and it's availability should be carefully considered.

When these conditions are met, an Edit button is available.

How can I edit a clinical note?

To Edit an existing clinical note:

1. Search for a patient.
2. Click Show.
3. In the Main Menu, click Clinical Notes.
4. Click Show for the clinical note you wish to edit.
5. Click Edit.
6. In the Text field, modify any content as needed.
7. In the Clinical Note Category field, select a different category if needed.
8. In the Case field, select a different case if needed.
9. Click Save Draft to save a draft version of the note for future editing; or,
10. Click Save Approved to finalise the clinical note. (A version number will appear , which is the number of times the Approved notes has been edited)

Disclaimer: Although the system allows you to edit a clinical note after approval, you should ensure you comply with any clinical best practice guidelines/legislation around editing existing clinical notes.

Auditing

See Clinical Note Audit Trail

Removing incorrect information

Where a note is wrong or irrelevant, you may wish to remove it in its entirety.

See Strike a Clinical Note

To comply with best medical practice, clinical notes cannot be deleted. However, you can Strike a clinical note, indicating that it should not longer be part of the current medical record. The Struck note is then visible under the Clinical Notes > History tab

To strike an existing clinical note:

1. Search for a patient.
2. Click Show.
3. In the Main Menu, click Clinical Notes.
4. Click Show for the clinical note you wish to strike
5. Click Strike.
   1. A confirmation message appears — click OK.
6. The clinical note then appears in the History tab and A new version of the note is created for audit purposes.

A clinic note can be unstruck by following these steps:

1. Search for a patient.
2. Click Show.
3. In the Main Menu, click Clinical Notes.
4. Click the History tab.
5. Locate the clinical note you wish to unstrike.
6. Click Unstrike.
   1. A confirmation message appears — click OK.
7. The clinical note is moved back to the Current tab and a new version of the note is created for audit purposes.