Introduction to Clinical Notes: Essentials

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  • Updated 3 years ago
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This article is the first in a series to help users get better acquainted with Clinical Notes in Front Desk. Front Desk offers a customisable clinical notes environment designed to give you a rich experience for creating and maintaining your own style of clinical notes. 

Front Desk provides several features for you to compose your clinical notes including:
  • Auto Complete for using shorthand when typing
  • In-built spell check with medical dictionary
  • Customisable templates with: 
                 o    Auto populating letter tags
                 o    Check boxes
                 o    Drop down lists
                 o    Tables
                 o    Editable images
  • Clinical Notes Types and Conditions/Regions/Stages for easy categorisation
  • A Reminders/Warnings/Contraindication field that is always visible
  • Editable Quick Buttons for easy text input - particularly on touch screens
  • Scrollable history of previous Clinical Notes
  • Embedding file attachments directly into your notes
  • Easy access to patient X-Rays/Photos
  • Copy Note function
  • Embeddable Letter Tags 
  • Revision records for notes edited outside of the defined revision period (if allowed).


Setting up basic clinical notes features

From the System menu in Front Desk you will find options to setup several clinical notes features in your system. We will cover all of these options over a series of articles with this article focusing on Clinical Notes Types and Clinical Notes Conditions/Regions/Stages.



Select Clinical Notes Types to view, create and edit your Clinical Notes Types. Clinical Note Types are designed to be a high level categorisation of your notes so that you can quickly identify and navigate a particular series of notes. At a basic level this may simply be a History note and a Consult/Treatment note, but you may wish to add others that form part of your standard note taking procedures such as Reviews etc. Note that the Chart check box indicates an image Clinical Notes Type such as a standalone body chart.



Use the Add, Edit and Delete buttons to manage your Clinical Notes Types.

The Clinical Notes Conditions/Regions/Stages feature acts as a secondary categorisation tool. This could indicate a condition, region or clinical stage. It is important to note that you can only associate one Condition/Region/Stage per clinical note so it is important to consider how you will use functionality depending on what is important to you.


 
Use the Add, Edit and Delete buttons to manage your Clinical Conditions/Regions/Stages.

Layout

Once you have created your Clinical Notes Types and Conditions/Regions/Stages, it’s time to see how these are used on the patient file. On the patient file in Front Desk you will find a Clinical Notes tab. Note that the order of the tabs in the patient file can be changed by right-clicking on any tab.  If your computer or profile is commonly used for Clinical Notes, you may wish to move the Clinical Notes tab to the top of the list, moving the tab to the left and making it easier to navigate to.

 

The Clinical Notes tab can be broken down into 5 key sections: 


 
          1. Reminders / Warnings / Contraindications

This is a static field allowing you to type in any important information such as clinical reminders, warnings or contraindications that needs to be visible at all times when in the Clinical Notes tab.

          2. Left Side Navigation and Practitioner Queue

The list on the left hand side of the Clinical Notes tab allows you to select and view all Clinical Notes for the patient, sorted by the date entered. This list allows you to see information regarding the Clinical Note, including the Date of Entry, the Clinical Notes Type, Condition/Region/Stage and the Practitioner who created the note. To make finding a particular note easier you can use the drop-down boxes above the list to filter by Clinical Notes Type or Condition/Region/Stage.

In the lower left you will find the Practitioner Queue, allowing you to view any waiting patients marked as arrived by the reception staff. By right mouse clicking over this area, you can set what should occur when you double click on a patient in the patient queue. The most commonly used action is to open the selected patient’s clinical notes tab.

          2. History Window

In this area you can see a scrollable view of the clinical notes history, based on the filters applied in the filter section above the Navigation pane to the left. There are a number of buttons on the top left corner of this area.

           Maximise the History Window.

  Change between a scrollable list of each note and a thumbnail preview of the notes.

           Interchange the position of history notes to either above or below the Active Clinical Note window. 

           Minimise the History View  from your screen.

          4. Right Side Control side bar

The buttons in this area provide the main high level functions for creating, deleting and printing clinical notes, in addition to inserting a template, copying a note or attaching files. 

There are 3 speed buttons that allow you to view Images/X-Rays, Quick Buttons and Attachments. You can also find the Auto Complete button and Help menu button at the bottom of this section. These tools will be discussed further in future articles.

          5. Active Clinical Note Window

This is your main workspace when creating a Clinical Note. You can double click inside of this section to bring up a full screen view of your note using the in-built Front Desk Word Processor. 

Creating a New Note

Select New Note to insert a Clinical Note on the Patient’s file.



Select the Clinical Note Type and click OK.



In the Active Clinical Note windows, you can now start writing your Clinical Note. The standard text editing tools are available to edit formatting, fonts, text size and colours.  



Auto Complete

To save time when typing your clinical notes, you can use the Auto Complete feature, which allows you to type abbreviated text and have the full extended text inserted when hitting the space bar, for example “ax = assessment” or “tm = treatment”. To create a list of Auto Complete phrases, select the Auto comp. button in the bottom right of the Clinical Notes tab.


 
In the Replace: box type in your shorthand (what you actually type) and in the With: box type the full term (which will replace your shorthand). Repeat the process as needed and select Close when you are finished.


 
After completing the steps above you will be able to start typing basic clinical notes. In the next article, we will cover the use of Clinical Notes Templates.

If you are looking at going paperless with Clinical Notes in your practice and require additional Front Desk licences, please contact the Business Care team on free call 1800 18 18 20, pressing 2 at the prompt or via email businesscare@smartsoft.com.au
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Timothy, Business Care Manager

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Posted 3 years ago

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