Description

The clinical evaluation screen is optional, designed for speed, ease, and simplicity. It can be tailored to the provider's preferences, similar to the customization available with the Advanced Progress Note screen.


Access

From the Main Menu, click on the Settings button located in the Office Activity panel, then select the 'Use Quick Progress Note' option. Afterward, click the Save button to display this screen.


Nota: 

There are two ways to configure the Quick Progress Note display:

  • Through the User Settings section, selecting the Use Quick Progress Note option.


  • Through the Staff & Providers screen, selecting the provider and then the Use Quick P.N. option in the General Options section.

Important: If the Use Quick Progress Note option is selected in the User Settings screen, it will automatically be displayed in the Staff & Providers screen and vice versa.

Sections
Botones
  • Cancel: Cancels the progress note.
  • Settings: 
  • Edit: Allows you to edit an open progress note. If the progress note is closed, the Addendum / Amendments screen will be automatically displayed, since a closed progress note cannot be altered.
  • Leave Open: When pressed, it allows you to leave the progress note open.
  • Save: Allows to save the clinical evaluation performed on the patient, as part of the progress note.
  • Print: Allows to display the previous progress note to be printed.
  • Previous: Returns to previous screen.


  • Side Bar: This section contains all the elements available to perform the clinical evaluation of the patient. These elements can be configured and organized according to the user's needs and preferences.


  • Patient Dashboard: This section shows the elements concerning the patient's clinical history. Each area provides functionalities that can be used during the clinical evaluation. The sections available are: 
    • Allergies: Patient's active allergies.
    • Evaluation Form History: Patient forms.
    • Evaluation Notes: List of evaluation scores by date and provider.
    • Immunizations: Patient's immunizations.
    • IV: IV's administered to patient.
    • Medication List: Patient's active medications.
    • Menstrual History: Patient's period history.
    • Nurse Notes: Nurse's notes.
    • OB Summary: Patient's obstetrical summary.
    • Pending Orders: Pending laboratory orders.
    • Physical Therapy Notes: Notes on physical therapy.
    • Problem List: List of diagnoses or active conditions of the patient.
    • Simple Vital Signs: Section where the last recorded vital signs are displayed. Also, vital signs can be recorded from this section.
    • Vital Signs: Patient's vital signs history.
  • Clinical Evaluation: In this section, the patient's clinical evaluation notes are documented. There are three views of this section:


  • Assessment & Plan: In this section, the narrative of the patient's clinical evaluation will be displayed according to the configuration made, using the “Keywords”. If there are no “Keywords” configured in the system, it will be displayed blank so that the provider can write the information. The user has two options to select the format of the patient's clinical evaluation narrative.


Option #1 In paragraph form


Option #2 In list form


Option #3 When the option “None” is selected


Tabs (Located on the right side of the screen)

  • Tab [Smart Box]: Screen where the user can select frequent phrases, medications, orders and procedures.


  • Tab [Reminders]: Screen where the user can use, such as task reminders. 


  • Tab [Closed Encounters]: This tab displays all the patient's closed encounters, where they can be viewed, downloaded and printed. It also has the option of "Services, where it shows the history of the procedure codes and diagnoses used in the closed encounters.


  • Service History: Screen showing the history of procedure codes and diagnoses used in closed encounters.


  • Tab [Summary]: In the tab the patient's clinical summary will be displayed.

  • Tab [Order Results]: This tab allows the management of the results of the orders sent to the patient.