Description

Screen used to create and store documents pertaining to a patient's medical history using templates.


Access 

  • Through the Side Bar section: To access Patient Notes, click the corresponding button on the Side Bar within the Progress Note screen. If the Patient Notes button is missing, click the Settings button on the Progress Note screen's toolbar. Then, choose the Side Bar Settings option. From the available items on the right, drag and drop the Patient Notes item into the items window at the lower left corner of any Side Bar category. Click the Save button to apply the changes. The Side Bar will update, and the Patient Notes button will now be visible under the chosen category.
  • Through the Search section: Click on the Search button located on the left side of the screen, then select the Patient Notes button.


Sections


Buttons

  • Print: Allows to print the selected document.
  • Add: Allows you to add a document with clinical content, which can be selected through a template.
  • Edit: Allows to edit the selected note.
  • Cancel: Cancel any unsaved changes on the screen.
  • Save: Save changes to the screen.
  • Previous: Closes the screen.
  • Notes Grid: Section where saved documents are displayed.
  • Note Details: Section where the note or template will be displayed.    
    • Title: Document title.
    • Confidential For: Identifies the user groups that will have access to the note.

Buttons

  • : This allows the Title field to be used for template selection.

  • : Open the edit template screen to create a new document or to edit an existing template.


Append

  • Allergies: Allows to register the patient's allergies to the document.

  • Diagnosis: Allows to register, the diagnoses of the patient to the document.
  • Procedures: Allows to register the patient's procedures to the document.
  • Vital Signs: Allows the patient's vital signs to be recorded in the document.