Outstanding Clinical Notes

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We would find it helpful to have a report that shows clinical notes that require completion, ie there should be a clinical note that corresponds to each of the patients appointments
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Janette

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Posted 3 years ago

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Joyaa Antares

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If this was acted on, I'd like to see it in the form that once can click on an icon to indicate the note is complete, and that Janette's suggested report shows all those (within a date frame perhaps) that don't have the icon clicked. This would cover the relatively common situation of a clinical note being started but left incomplete ....
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Mark Banks

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That would be a good idea Janette.
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Timothy, Business Care Manager

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Hi all. We do have a feature on the appointment book that allows a user to hover their cursor over a practitioner's column to see patients that have not had clinical note written by that practitioner on the selected day. See below:



To enable this, head to System Information > Clinical Notes and ensure the follow setting is checked:



We will of course leave the idea open for further feedback.
(Edited)
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Joyaa Antares

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Thanks Timothy - that's good to know. I'd like to leave my suggestion here for others to consider too - "I'd like to see it in the form that ONE [not "once"] can click on an icon to indicate the note is complete". Best, J.
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Wendy Mallet

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I would like to see this report implemented so that we could more easily monitor the status of missing clinical notes. Would be good to include an indicator as to whether patient was billed or not to more easily identify DNA/No Show patients that don't necessarily need clinical notes.
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Joyaa Antares

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1. I agree with re. clinical notes status.
2. "Billing" is not synonymous with DNA, so it's better to use a different indicator for no shows. Currently we use the appointment status to reflect this (we have it as black, indicating they have a black mark against their name, hee hee). However, I don't think it's possible to run a report by appointment status (is it?), at present. Timothy/Gerry et al: what would it take to implement this?
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Ashlee

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Hi, 

I would also like to see a report which shows us any clinical notes that are outstanding. The problem with the current system is that its manual and requires you to check each column everyday, instead of just showing you a list that can be filtered to give to each practitioner. Another issue is that if the practitioner adds a new not, but types nothing in it, it doesnt show up as an outstanding note. This means that they can add blank notes and no one will pick it up. 

I would also like to see a function that allows you to switch off the "copy current note" function for practitioners, as all clinical notes should be unique and this can cause a major legal issue if they use it and is extremely time consuming to police. 
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Timothy, Business Care Manager

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Hi Ashlee. We do like the idea of an outstanding clinical note report and will consider this for a future update.
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Ashlee

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Thanks for your response Tim. We think that this is a very important issue, and is currently a major deficiency in the software as it is not just about running a marketing report etc, but about allowing the practitioners to meet their legal responsibilities. It could mean the difference between a person keeping their registration as a practitioner and therefore is possibly the most important part of a software package. 

I would really encourage you to look at being able to switch off the "copy current note" function as well as it is actually illegal to copy the notes from a previous consult and as the software does nothing to flag that this has been done, it is actually opening us up to major legal issues. 
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Timothy, Business Care Manager

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Hi Ashlee. We believe we already have functionality that allows practitioners to comply with their obligations in regards to clinical notes, however we are looking at adding a report in addition to the information provided in the tooltip when hovering over a practitioner name in the appointment book, when our development scheduled allows.

We would suggest that most practitioners would not like the additional burden of needing to mark a clinical note as complete, but rather it should be part of their own procedures to check on a daily basis that they have completed this requirement, particularly while the patient consultation is fresh in their mind.

In regards to the Copy Note feature, we can’t agree that this is contrary to any clinical note taking requirement. It provides practitioners a basis to be able to complete their notes more efficiently for subsequent consultations. Obviously, copying and pasting the previous note with no thought or editing of what is different between the two consultations is not the intent of this feature.

We are looking at adding a report that shows no clinical note added for an appointment in a certain date range, and perhaps additional information such as as those clinical notes under a certain number of entered characters. We are happy to hear how others are using the Copy Note feature and if it should be removed or disabled.
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Michael

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Hi all,

Copying notes is something I would also like to see removed or limited - I know that it can be a time-saver, however with the ever increasing regulatory environment for health professionals, the risk v reward component re: copying notes just isn't worth it. I'm not exactly sure what a work around would be (perhaps a "history" section with the option "copy history to notes" available for ongoing chronic conditions?). While I'm not sure what the solution is right now, I am sure that the ability to copy the previous notes verbatim is a big risk.  

Similarly, with regards to checking clinical note completion, I've found that commencing a note and then closing it is still counted as a clinical note when doing the report/hovering over the column. As you've noted above, this could be combated by a minimum character limit but that will likely be a can of worms. I'm aware that making a confirmation button isn't efficient, but what if there is a "save and return" option or something like that? Say something similar to a submit/complete button but could be used to remind the clinician that they need to go back to them.


Cheers

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David Ayres

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I would think the copy previous note could be allowed or disallowed in security settings so we can choose to allow or disallow copying depending on our own preference.  

As far as the clinical notes status It would be good if the clinical notes window had a 'Save as Final' and 'Save as Draft' button like the button below instead of the 'close' button.   Perhaps then a report could be generated for those that are saved as drafts for a period of time with a particular practitioner and/or the status of the clinical note shown on the appointment? This would cost practitioners no further time than clicking close as they do now but help them workout which ones they have to go back and complete, which currently means they have to open the notes for each client to check.

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Valerie

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I agree that this needs to be either restricted or removed as this could directly affect any legal matters if anything happens. Also, private health funds do not condone copying of previous notes as they want to make sure the client is not being over-serviced. This would very much benefit my business. 

I also agree that a report of some sort needs to be made available instead of manually checking if there are any outstanding clinical notes. This should have been automated in the first place. 
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Kat

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I totally agree with all the above, this needs to be restricted since day one. Copying of notes shouldn't be an option to avoid any legal issues.

A report of outstanding clinical notes would help with the performance review we have quarterly and it reduces admin time for me if this is automated. Imagine the admin time it reduces for all the people involved in this post and want this to happen.
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Timothy, Business Care Manager

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Hi all. We appreciate the feedback we are receiving regarding this matter. Please keep the feedback coming for further consideration. 
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Kim Royals

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Excellent idea, if its not possible to completely withdraw the the copy note function can it be restricted. This will prevent and future legal issues and some piece of mind personally.

A report of outstanding clinical notes would eliminate admin time and human error scrolling over the practitioners name. This again ensures no future legal issues about the integrity of the notes being completed in a timely manner and my own piece of mind knowing we have all our bases covered with no outstanding or copied notes. 
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Scott

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Seems to be a lot of great ideas on this thread at the moment!

A clinical notes report would be a great way to efficiently manage our staff and make sure they are continually complying with their legal obligations to write and maintain clinical notes for a client. As mentioned above, it is some what time consuming for a practice of 7 therapists to go through each of these notes on a daily bases and make sure they have been finished. The current ability to see the list when hovering over the practitioner name is good, but it does let slip through those who have started a note and not finished it. While some may like this and other may not, maybe it would be best to add the function to allow some therapists to access it and other not - just like you can do with the clinical notes quick buttons

As for the copy note function - again I think David's idea of being able to save a draft or save and finish would be excellent. No extra time for the therapist at all. I do understand that the function is there to make things more time efficient for therapists and that intention is not for identical clinical notes to be produced, however, with the inability to tell if someones note has been marked as finished we have the same issue as mentioned above. This means that by hovering over the top of the list at the end of they day they think they have been completed when in actual fact they have only copied the note from above and made no changes. 
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Rachel Bruce

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Adding a note completed button or an "electronic signature" possibly with a time/date stamp would be fantastic.

Once a clinical note is generated, there is no other option than to manually check these have been completed which is a very time taxing exercise.

We would LOVE to be able to run a simple report on this as part of our KPI's instead of a tedious manual check.

Thanks,
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BaiMed Business

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I would like to add that we would also really like to see a report added that allows us to get a summary of all of the outstanding clinical notes for each practitioner. It is not practical to have to hover over each practitioner each day and manually enter the outstanding patient notes it into a report. It is very labor intensive and time consuming - especially due to the fact that this is a weekly report that we send out to each practitioner and we include all clinical notes that they have missed from the beginning of when we starting to use the system so the longer we use it for, the more days we need to hover over and it is just not possible with the current process.