How to Add a Clinical Note

Clinical notes record consultation history, examination findings, and diagnoses on a patient's record. They are displayed in the Clinical Notes section at the bottom of the Clinical Summary tab.

Clinical notes are displayed in the Clinical Notes (Medical History) section of the Clinical Summary tab. You can view them as individual records or in a continuous view. Set your preference at File > User Preferences > Clinical Details > Default Clinical Notes View.

Add a Clinical Note

Open the patient record and go to the Clinical Summary tab.
Select New above the Clinical Notes section.
If prompted, select an episode to associate the note with, then click Select.

Episodes group related consultations together. For example, if a patient has diabetes, you can capture all consultation notes relating to their diabetes into a Diabetic episode. This makes it easier to review a specific condition's history.

Select a category from the Summary drop-down and/or enter a description for the consultation.
In the top text field, record the History and/or Examination details. Use the Hx and Ex buttons to insert Smart Text templates.
In the bottom text field, use the Dx button to add a Condition, or the Procs button to add a Procedure.
Select Finish at the top of the screen to stop the consultation timer when the patient's consult has ended.
Select Save.

You can also add a clinical note directly from the Diary by right-clicking a booking and selecting Go to Clinical Note (F4 ).

Edit a Clinical Note

A clinical note can be edited for 24 hours after creation, by the user who created it.

Select View above the Clinical Notes section in the Clinical Summary tab.
In the General Consultations window, confirm the Category view is selected in the top left.
Highlight the note to edit.
Select Edit.
Make the required changes.
Select Save.

Amend a Clinical Note

After 24 hours, a note can no longer be edited, but it can be amended. Amendments appear below the existing history and examination content.

Select View above the Clinical Notes section in the Clinical Summary tab.
In the General Consultations window, confirm the Category view is selected in the top left.
Highlight the note to amend.
Select Amend.
Enter the amendment details.
Select Done.

By default, only the user who created a note can amend it. The ClinicalSummary_ClinicalNotes_Amend permission allows a user to amend any clinical note. Speak to your administrator if you need this access.

Delete a Clinical Note

Deleted clinical notes cannot be restored

Select View above the Clinical Notes section in the Clinical Summary tab.
In the General Consultations window, confirm the Category view is selected in the top left.
Highlight the note to delete.
Select Delete.
Confirm the deletion by selecting DELETE in the confirmation dialog.
Enter a reason for the deletion, then select Done.

Deleting clinical notes requires the ClinicalSummary_ClinicalNotes_Delete permission. If the Delete button is unavailable, contact your administrator.

Security Permissions

The following permissions control access to clinical note functions. Administrators can assign these through security groups.

Permission	Description
ClinicalNotesSecurityAdmin	View all secured clinical notes and change security settings on records (does not allow editing the record itself).
ClinicalSummary_ClinicalNotes_Amend	Amend any clinical note, not only notes created by the current user.
ClinicalSummary_ClinicalNotes_CreateNew	Create new clinical notes from the Clinical Summary screen.
ClinicalSummary_ClinicalNotes_Delete	Delete any clinical note, not only notes created by the current user.