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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