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manual:organisation_administration_progress_note

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Progress Notes

On this tab, you will be able to tailor a range of drop down lists affiliated with Progress Notes to make them suit your organisation's requirements. The fields you can manage in this tab are found here in the Clinical Summary tab of the patient record:

Configuring this section is not mandatory, if you make no changes, your organisation's users will see the default MMEx options.

Progress Note Configuration

In the org centre on the Progress Notes tab you will be able to define lists of data items that can be used to define progress note attributes such as Presenting complain, reason for contact, visit type etc.

These data sets can be used to support capturing information and reporting on clinical activity and occasions of service. There are two types of data fields:

  • Coded Attributes - utilise SNOMED CT to create coded data sets
  • Metadata Fields - create custom lists of items that define the properties of a progress note/occasion of contact

Coded Fields

Coded Fields are fields that utilise the SNOMED picker.

You have the option to define the display name for multiple SNOMED fields. Click on Add New Coded Attribute to define a new coded list.
You will see a range of fields to complete.

Select an

  • Attribute Type (NB: you may only have one field of each type configured):
    • Treatment
    • Finding/Diagnosis
    • Allergen
  • Display Name - define what you want the field title to display as in progress notes
  • Allow Multiple - check the box to allow users to select multiple options from this list
  • Custom Terminology List - select a custom terminology list that you have defined previously.

Your defined Coded Attributes will display in a table. Click on Edit from the Action menu to alter the properties.

Other Actions

On the actions menu for each defined Caded field, you have the option to:

  • Edit - modify the properties of the list
  • Supersede - create a new list to replace this one with the same master properties but no defined content
  • Archive - remove a list from use.

Metadata Fields

Click on Add New Metadata Field to create a new list of data items that users can use to define the progress note attributes. You will see a range of fields to complete to define the list.

Select:

  • Display Name - define what you want the field title to display as in progress notes
  • System Tag - tag the field, for reporting purposes, as
    • Event Title - eg Reason for service
    • Consultational Type - marks the field for inclusion in occasions of service reporting
  • Strongly Recommend- check the box to include a prompt for staff to select data items for each progress note. This also marks the fields with an asterisk and keeps them visible even if the user clicks “Hide Details”
  • Editable if amending - check box to allow editing of the data items if the progress note is being amended

Once the list properties are defined, configure the list items. Click on Add New Value

  1. Give the item a name and a category (if desired not mandatory)
  2. Mark if the item is the default selection.
  3. Uncheck Is consultational box on Consultation type lists, to mark that the item should not be included in occasions of service consultation counts. (NB: this box should be checked for most items. Administrative notes would NOT have this field checked.)

Your list will be defined.

Create a metadata field for each of the pieces of information you wish to collect about progress notes and occasions of service.

Define the display order

To determine the order in which these metadata attribute fields display in the progress notes attribute section, click on Change Display Order

You will see the screen displaying the fields that will be:

  • Shown (Visible) By Default - users are unable to hide these fields
  • Hidden By Default - users will reveal/hide these fields by clicking on Show Additional Fields / Hide Additional Fields button on the progress notes page.

Drag and drop to move items between the lists and determine their placement order.

NB: When you return to the Progress Note Settings screen, the list will display the order number for each item in the Sort Order column. Sort the list by clicking the sort order column heading to display the list in sort order.

manual/organisation_administration_progress_note.txt · Last modified: 2019/11/23 06:06 by sarahb