Note: There are several options for documentation in the Clinical Evaluation screen.


Option #1: Writing in the assigned area

  • Go to the Advanced Progress Note screen.
  • Click the left mouse button on the line below the title you want to document in the Clinical Evaluation section.


  • Record the patient's clinical evaluation information. 

(Note: In this example, in the Chief Complaint field, the reason for the patient's visit or chief complaint is written.)

  • Once you have finished, press Enter on the keyboard. Or, press the right mouse button outside the selected line.
  • Repeat the same step for each of the Present Illness, Past History, Physical Exam, ROS or Triage sections.
  • If another provider or authorized user clicks on the selected options of another provider in the clinical evaluation, the following message will be displayed: (You must have the Lock Clinical Evaluation provider selection option selected in the Settings / General / General screen).


Important: The sections displayed in this section are configured in the Advanced Progress Note / Setting / Clinical Evaluation Template Setting screen.


Option #2: Select already customized options

  • Go to the Advanced Progress Note screen.
  • Press the Chief Complaint, Past History, Physical Exam, ROS or Triage button, located in the Side Bar section.


  • Or, press the Search button located at the top left of the screen and select the Chief Complaint, Past History, Physical Exam, ROS or Triage options.
  • The following screen will be displayed, depending on your selection.


  • Select the options to document the clinical evaluation of the patient.
  • Once you have selected the options corresponding to the clinical evaluation of the patient, press the Save button located at the top of the screen.
  • The selected options will automatically be displayed in the Clinical Evaluation section.


Option #3: Through sentences

  • Go to the Advanced Progress Note screen.
  • Click the left mouse button on the line below the title you want to document in the Clinical Evaluation section.


  • Then press the button, where the three dots appear.


  • The following screen will be displayed:

          

  • Select the phrase you wish to incorporate into the clinical evaluation.
  • Once selected, press the Apply button, located at the bottom of the screen.

         

  • It will automatically be displayed in the Clinical Evaluation section.


  Option #4: Through Templates

  • Go to the Advanced Progress Note screen.
  • Press the Chief Complaint, Past History, Physical Exam, ROS or Triage button, located in the Side Bar section.


  • Or, press the Search button located at the top left of the screen and select the Chief Complaint, Past History, Physical Exam, ROS or Triage options.
  • The following screen will be displayed, depending on your selection.


  • Press the Select Template button, located at the top of the screen.


  • The following screen will be displayed:


  • Select the Template you wish to add to the clinical evaluation.
  • Once selected, press the OK button located at the bottom of the screen.


  • The following confirmation message will be displayed: 


  • Press the Yes button to add the Template to the clinical evaluation.
  • Press the No button to cancel the action.
  • Once the clinical evaluation is completed, press the Save button.
  • It will automatically be displayed in the Clinical Evaluation section. 



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