Clinical Notes

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Clinical Notes Window

Patient>Clinical>Clinical Notes

With the Clinical Notes window, you can enter notes that appear on the specified documents such as Orders, Charting, Care Plans, On-Call Summary, Intermediate Summary, Discharge Summary, HCFA-486, and various reports or view all notes for a patient. You can also attach clinical notes to the service.

Use codes define areas or documents on which clinical notes will appear. The default use codes are predefined on the Business Units level.

For Hospice patients, to be able to enter clinical items relating to bereavement plans of care, the application generates an open-ended certification period that begins on the day of death. All prior clinical items are terminated with the death. Only clinical items that are done on the day of death generate supplemental orders.

Entering Clinical Notes for a Patient

1.	In the Patient component, select the needed patient.

2.	If you plan to add new clinical notes and want to connect them to a particular visit, select this visit in the corresponding field on the toolbar. Any newly added clinical notes will be automatically connected to this visit. You can set this connection later manually, if needed (see Step 8).

3.	Go to Clinical>Clinical Notes.

4.	To add a new note, click Add Row. To edit, make changes or additions to the notes as appropriate.

5.	Enter the clinical note in the Note field.

6.	Click the ellipsis button in the Use Code field, and then select the clinical documents where the note should appear.

7.	Complete the other fields as appropriate.

Depending on the use codes you selected, the required for saving and available for completion fields may vary.

8.	If you want to connect the clinical note to a specific patient visit, phone call, or the resource or if you want to change the connection, click Change and define the needed options in the Select Date Dialog.

Clinical notes of type S, H, and B must be connected in order to save. For other types, it is not obligatory, but leaving clinical note unconnected will invoke a confirmation message on save suggesting to connect it to the currently logged in resource. If the resource has one role, the corresponding resource type is assigned automatically; if the resource has multiple roles, the dialog opens for specific role selection.

9.	Save your changes.

If you connect clinical notes of type H and B and their combinations with C and P to the same resource as that you are currently logged in or to a visit by this resource, the Electronic Signature dialog appears. Enter your login password, click OK and clinical note will be saved as electronically signed. If you click Cancel, clinical note will be connected to a visit or resource without electronic signature.