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Add Clinical Notes

Aravind
Aravind
Updated Recently

Overview

How to add Clinical Notes

You can also add “Clinical notes” for the appointment by clicking on the “Add Note” button at the top of the Appointment Details Page.
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Add Clinical Notes

By clicking on the Add Notes Button, you will be redirected to the clinical notes page.

In the top left corner, you will see three types of Clinical Notes:
  • History and Physical Notes
  • SOAP (Subjective Objective Assessment Plan) Notes
  • Additional Notes

If you click on any of the note types, you can see various notes under each clinical note.

History and Physical Notes

For instance, under History and Physical Notes, you will see:
  • CC/History of Present illness
  • Med/Fam/Social History
  • Review of systems
  • Physical Exams
  • Plan
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Add Clinical Notes

SOAP Notes

Under SOAP Notes, you will see various notes like:

  • Subjective
  • Objective
  • Assessment
  • Plan
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Add Clinical Notes

Customized Forms

The forms built using Form Builder will be listed under the Additional Notes.
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Add Clinical Notes

Once you select the appropriate note, fill in the relevant information in the designated fields.

Ensure that all sections are completed as necessary, providing clear and concise details about the patient's condition and care.

Preview Clinical Notes

You need to enable the “Include in Note” toggle switch to view and save the entered details in the preview note.

Once the clinical note is completed, click the “Preview Note” button. This action will generate a PDF of the clinical note for review.
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Fax Clinical Notes

You can see revisions of the clinical note by clicking the Revision Button.

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Revise Clinical Notes

In the Revision popup, you can see the note information based on the “Date of Appointment”, “Locked by(Admin name)”, “Locked at(Date & Time)”, “Supervisor Locked by(Provider name)”, “Supervisor Locked At(Date & Time)” with Revision details “Pdf Generated at(Date & Time)”, “Locked status”, “Supervisor Locked status”.

A revision is saved when the note is locked, an amendment is added, and sometimes while editing an unlocked note.

If another user has any comments regarding the notes they can add those comments in the “Amendments” section.

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Enter Amendments

To Add Amendments click on the “Add Amendments” button, this opens up a popup in that popup the user can add “Comment” and click on the “Add New” button to save the amendments.

After reviewing the clinical note, the provider should click the “Sign and Lock” button to lock the clinical note. This ensures that the note is finalized and cannot be altered. If you want to unlock the clinical note click on the “Unlock” button to unlock the locked notes.
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Preview Clinical Notes
create appoinment
Preview Clinical Notes

Send Fax

If you want to send a Fax, click the “Fax Queue” button. A form will pop up.
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Send Clinical Notes via Fax

Select the provider you want to send a Fax to, enter the Fax Number, and Write any message you want to send. Click Send Fax, and the clinical note will sent to the provider via Fax right away.

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