Clear plan management, diagnosis, frequency and exercise prescription section within clinical notes to be compliant

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With current changes to the need for note taking to be compliant for insurance companies etc, we need an extra space within the clinical notes to set up diagnosis, plan management, relevant re-e examinations needed and frequency of care. THis would also be a good space for us to be able to set up which exercises to prescribe and when they have been prescribed (so all practitioners can be on the same page quickly.)This area needs to be able to be populated with quick buttons (unlike the warnings/ contraindications section).
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Andrew

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Posted 3 years ago

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Joyaa Antares

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Andrew - do you see this as separate notes or pages for each of "diagnosis, plan management, relevant re-e examinations needed and frequency of care."?  Or would you set up your treatment template - which is a facility that exists already - to include these sub-headings?
Rgds, J.
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Andrew

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Hello Joyaa- the treatment template not the right place as it disappears from easy view after 2 treatments.  So for example i can not see if a patient has already been prescribed and exercise if they have seen another practitioner unless i scroll through previous notes.  That means i cant ask if they need help with the exercise or remind them to do it (so we are all on the same page).  
I see it as a separate note section (under  the warnings section i had in my head.
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Steven, Business Care

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Hi Andrew

The problem that we face as programmers is that most practitioners want to do clinical notes in a different way. At this stage our approach has been to provide a canvas for you to develop your own clinical notes templates and methodologies so that you can set up Clinical Notes in Front Desk for what suits you best. Using a combination of autocomplete, Clinical Notes templates (tables, checkboxes, editable images, drop down lists), Clinical Notes Types (History, Treatment etc), Condition/Region/Stage, programmable quick buttons, x-rays, body charts and file attachments you can develop a clinical notes methodology that is right for you.

I understand that this can take a bit of time to set up, but we believe in giving you the flexibility to create this yourself. Having said this, we are happy to hear what people are interested in regarding clinical notes for future development. Perhaps you can mock up a screen, or describe your idea in a bit more detail so that other users can comment as well.

We appreciate the complexity of this topic and have decided to release a series of articles on creating Clinical Notes over the next week, keep an eye out if you are interested.
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Steven, Business Care

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Hi Andrew
We want to thank you for putting in the time to create a fantastic video that highlights your needs. We are hoping to make a time with you early next week so that we can personally discuss your thoughts on some future developments for Clinical Notes.

Can you please open a support case at www.smartsoft.com.au/support so that we can arrange a time to discuss further sometime next week.

Have a great weekend!
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Paul Mudge

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Regarding the articles on creating clinical notes as suggested in the post, has this happened yet and if it has where would I find them?

Thanks

Paul
 
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Timothy, Business Care Manager

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Hi Paul. Our apologies, we have prepared drafts of the initial articles in this series, but we have been busy preparing the latest upgrades over the last few weeks. We will aim to release the first two articles next week. Thanks.
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Andrew

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Hello Timothy.  Are we any closer to having a section in the clinical notes that we can record exercises given, management plans etc, so our practitioners can be on the same page.  We are using clincial notes exclusively now, but it falls down when we try and find any home care recommendations given, or see a planned rehab process to see where we are at.
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Andrew

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thnaks for REply Steven. It may well be set up to be able todo what we are after, but i just havent discovered it yet.  We want the podiatrist to be on the same page as everyone else also!. so our care is truly supprted by the team.

It is just a blank box as outlined in video so we can put running notes etc rather than any of our practitioners having to search them.
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Joyaa Antares

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Andrew - If you talk through your ideal with Steven and the crew at SS I reckon they'll be able to help you set up a suitable template structure.  Don't forget that "template" isn't just something you use at the initial session - like a history template - you can have a treatment template too - and in your case your treatment template may comprise a series of headings.

One other thought - currently it is a limitation (as I see it) with the clinical notes that you cannot select to see the notes pertaining to a specific practitioner - at least I cannot in 16.9.4.  So when you have multiple practitioners treating a single patient this can be a pain and I think this is what you are alluding to.   A workaround I have used in this situation is to assign all the treatments given by one practitioner (me !) a specific Condition/region/stage - call it low back pain (LBP) and give it a green colour, and (in my case I didn't assign a condition to the other practitioner's treatments.  So then I could select to see only the LBP sessions and so I could easily see what exercises I had suggested previously.    Hope this makes sense!
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Andrew

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My problem is that no matter the template I use they are quickly removed from easy view. Is there a way I can have one put to one side that is always visible?
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Joyaa Antares

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Sorry - storm here (QLD) - intermittent internet.  
1. Set up a clinical notes *template* that contains the subheadings you need.  Type these subheadings in with appropriate space to fill in details later
2. At this stage, just call this something like treatment-headings to distinguish it from your normal treatment template
3. Now, go into a patient's clinical notes; click on "New Note" and choose "treatment-headings".  Do this every time this practitioner wants to use this template.
Let us know how you get on.
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Andrew

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maybe this might help me be more clear.
http://screencast.com/t/c2Kc4T73T08s
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Andrew

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so its not the clinical note template Steven, as i am working with that, its having somewhere for the diagnosis, management plan and prescribed exercises so that all 11 practitioners that work here can quickly be on the same page and support the patient, without the practitioner having to go back through each treatment to find a plan and what is currently being done.

This also helps us not look stupid by receomending a certain exercise or to read a certain book, when it already has been suggested.  Better flow and care for the patient on other words
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Andrew

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here is an area i would suggest to have this box.

http://screencast.com/t/XHdl4qSZedOg
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Joyaa Antares

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Sounds super Andrew. Simple, clean, straightforward and gets our vote.
Sounds rather like a Reminders/Warning/Contraindications box, except this one would say Diagnosis/Management plan/Prescribed exercises. Yes?
The only downside I can see is that some of our practitioners use laptops with relatively small screens, and the creation of this extra box would create some visual issues for them. However, it's a smaller issue than having to trawl one's way through the treatment notes to find the prescribed exercise/s etc.
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Andrew

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Exactly Joyaa.  The only difference would be that we could use quick notes to populate.

We purchased the biggest touch screens we could find for maximum screen realestate.  helps with my unco fingers
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Joyaa Antares

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Hi Andrew, Hi All,


I am following up on this because I am reviewing how we record exercises within our clinical notes. Seems to me a good approach will be to set up a new "clinical notes type". Currently we have History, Treatment, Notes (telecon etc.) and Chart. I am thinking to add "Exercises". This way, when I want to see all exercises recommended to a patient/client I can easily select to view only the "Exercises" notes type and then see everything at a glance.


(Obviously, this won't apply to exercises recommended before I add the new template, unless I choose to go back through the clients' notes to set up correct-date Exercise notes for each. Not out of the question but will take this on a person-by-person basis).


Does this help? Joyaa
(Edited)
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Andrew

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might just help. do you think a tick box chart could be added that all the exercises are on, that we tick the box when we prescribe that particular exercise.  would need to be automatically dated though.  i wonder if this can be done
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Joyaa Antares

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That sounds fairly easy to achieve:
1. Create the "exercises" clinical notes type as above
2. Create a clinical notes template (specifying "exercises" as the type), using the which will be a tick box chart set out/formatted in the way you want. (You can probably use a combination of a text form field for the exercise, plus a check box form field at the end of each line. I haven't used either of these in the past, so I am guessing this is what they are for [pls let me know!)
3. This should give you your template. Then use this when you prescribe an exercise or set of exercises.
4. Then, if you want to add or remove an exercise 3 weeks later, go back to your original "exercises" clinical note, click on "Copy Note" to give you a new sheet of exercises with today's date, and amend the new sheet as needed.
Bob's your uncle.
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Andrew

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we have experimented putting exercises in the warning area at the top, but as this isnt a part of the notes and can be deleted, it is not acceptable to ahpra when we go to sow management plans.

your way could work and be easy for a practitioner to find quickly