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Clinical notes overview

Clinical notes are notes for a patient's exam and/or treatment that are not specific to a procedure. You can view a patient's clinical notes from the Patient Chart. (You can also view the clinical notes from the Ledger and Family File.)

To view a patient's clinical notes

With a patient selected in the Patient Chart, on the File menu, click Clinical Notes.

The Clinical Notes window appears.

The clinical notes are arranged by date, note number, and then page. You can have as many notes as you want, with a maximum of 10 pages per note.

The Clinical Notes window has buttons for adding, managing, and printing clinical notes. The function of each button is explained in the following table.

Click the New Clinical Note button to add a clinical note. The new clinical note will be inserted under the current system date and given the next available note number (Note#[number]) as an identifier for that date.

Click the New Clinical Note Page button to add a page to a selected clinical note. This button is available only if a clinical note is selected.

Click the New Addendum to add an addendum to a selected clinical note page that has been signed or locked according to a certain global setting. This button is available only if a clinical note page that is locked is selected or if a certain global setting is enabled.

Click the Delete Clinical Note button to delete a selected clinical note or page of a clinical note. You can only delete one clinical note at a time. This button is available only if a clinical note or page is selected and the note is not locked (locked notes have an asterisk next to the page number).

Click the Save Clinical Note button to save the selected clinical note. This button is available only if a clinical note page is selected and the note is not locked (locked notes have an asterisk next to the page number).

Click the Copy Clinical Note button to copy the text of the selected clinical note or page of a clinical note to the Windows Clipboard. This button is available only if a clinical note or page is selected.

Click the Copy All Clinical Notes button to copy the text of all the patient's clinical notes to the Windows Clipboard.

Click the Sign Clinical Note button to sign the selected clinical note. Once a clinical note is signed it cannot be edited or deleted, but it can be appended. This button is only available if a certain global setting is enabled and a clinical note page is selected.

Click the Insert Date/Time button to insert the current system date and time and currently logged-in user ID where the text cursor in the current clinical note is located ar at the end of the note page that is currently selected. This button is available only if a clinical note page is selected.

Click the Change Encounter for Selected Note button to change the number for the selected clinical note. This button is available only with a certain global setting enabled and either a clinical note or page of a clinical note with an encounter number is selected. (If a note has an encounter number selected, the number appears in square brackets next to the note number.)

Click the Change Provider for Selected Note button to assign a different provider to the selected clinical note. The default provider is the current charting session provider selected for the Patient Chart (however, in other modules, the default provider can vary, depending on the module). This button is available only if a clinical note page is selected.

Click the Change Clinic for Selected Note button to assign a different clinic to the clinical note. The default clinic is the clinic you are logged on to (this is also true of the Family File and Ledger, but for the Appointment Book, the default clinic is the clinic of the view being used.). This button is available only if a clinical note page is selected.

Click the Print button to print clinical notes for the selected patient and/or the current patient’s family members.

Click the View Prompts button to view only the information that was inserted into the current clinical note using clinical note templates with prompts. This button is available only if the note has been signed or locked.

Click the Expand All button above the left pane to view clinical notes for all dates in the left pane.

Click the Collapse All button above the left pane to reset the left pane to show only the date categories for the patient's clinical notes.

If you have text selected in the current clinical note, click the Cut button to remove the selected text and place it on the Windows Clipboard.

If you have text selected in the current clinical note, click the Copy button to copy the selected text and place it on the Windows Clipboard.

Click the Paste button to paste any text on the Windows Clipboard where the text cursor in the current clinical note is located.

Click the Check Spelling button to check the spelling of the the selected clinical note page. This button is available only if a certain preference setting has been enabled.

Click the Expand All button above the right pane to expand all the clinical note template categories.

Click the Collapse All button above the right pane to rest the right pane to show only the clinical template categories.

Click the Template Setup button to open the Template Setup dialog box to add, edit, and delete clinical note templates.

To learn more about clinical notes, click any of the following links:

·        Adding clinical notes

·        Adding clinical notes using templates

·        Clinical note templates

·        Editing clinical notes

·        Adding an addendum to a clinical note

·        Deleting clinical notes

·        Printing clinical notes

·        Copying clinical notes to other programs

·        Signing clinical notes

·        Searching clinical notes