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 (Medical History) section at the bottom of the Clinical Summary tab.

Add a Clinical Note

1. Open the patient record and go to the Clinical Summary tab.
2. Select New above the Clinical Notes section.
3. If prompted, select an episode to associate the note with, then click Select. See the Episodes of care section below for how episodes work.

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

Episodes of care

Episodes group related consultations together so you can review one condition's history in one place. For example, if a patient has diabetes, you can capture all consultation notes relating to their diabetes into a Diabetic episode.

When you create a new clinical note, HealthTrack prompts you to choose an episode before the note opens. You can:

• attach the note to an existing episode for the patient
• create a new episode using a preset
• create a new custom episode without a preset
• continue without attaching the note to an episode

You can set a default episode in File >  User Preferences > Clinical Details > Default Episode Description, so it is pre-selected each time. Your administrator can also turn the episode prompt off for the practice, in which case notes are created without asking.

Edit a Clinical Note

A clinical note can be edited for 24 hours after creation, by the user who created it. After 24 hours the note can no longer be edited, only amended (see the next section).

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

Amend a Clinical Note

After 24 hours, a note can no longer be edited, but it can be amended. Amendments are added below the existing history and examination content, stamped with the date and the name of the user who made them. The original note text is never overwritten.

1. Select View above the Clinical Notes section in the Clinical Summary tab.
2. In the General Consultations window, confirm the Category view is selected in the top left.
3. Highlight the note to amend.
4. Select Amend.
5. Enter the amendment details.
6. 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, at any time. Speak to your administrator if you need this access.

Delete a Clinical Note

1. Select View above the Clinical Notes section in the Clinical Summary tab.
2. In the General Consultations window, confirm the Category view is selected in the top left.
3. Highlight the note to delete.
4. Select Delete.
5. Confirm the deletion by selecting DELETE in the confirmation dialog.
6. 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.