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Progress Notes

Adding a Progress Note

With a patient record open, select the Clinical Summary page, where there will be a section to add and review Progress Notes:

  • from the Navigator or
  • from the Patient Widget

Your organisation will have configured some fields for you to record specific data in your progress note such as Reason for Contact, Visit Type, Mode etc. Refer to your Organisation Administrator for additional information about these fields and what is required of you.

Complete the drop down arrows in the configured fields and place your cursor in the progress note text box and start typing. Your notes will save periodically. If your organisation has strongly recommended fields to complete, the auto save message and save will confirm if these fields have not been completed. Other features in the Progress Note include:

  • Show Additional Fields/Hide Additional Fields - Allows users to show or hide reporting fields within the progress note
  • Privacy Level - privacy of an individual note can be set here. Options display according to role permissions
  • Date and Time - display automatically at the date and time of the progress note being written
  • Insert Template - templates can be set by the organisation or by individual users and when selected will be inserted into the progress note space.
  • Draw Sketch - add a sketch to a progress note
  • New Observation - opens Add Observations Record and observations will be saved to Observations and Recent Patient Actions to be included in the Progress Note
  • Replace Shortcuts - shortcuts can be defined at user and organisation level. When used clicking this button replaces the abbreviation with the configured detail
  • Recent Patient Actions - displays actions, by any user, that have been completed in the patient record since the last progress note was created. User may select the items they wish to be attached to the progress note they are writing.

Auto-populating Observations

Observations can also be added by clicking the New Observations button, entering the Observations and click Save. They will then display as a Recent Patient Actions list and able to be linked to the progress note, unless unchecked manually.

In addition to adding observations directly, when you enter data into a progress note, observations can be entered in such a way as to auto-populate the Observations List.

To auto-populate the data needs to be entered as follows

   [Observation Type] : [data]. 

For example: BP:110/75 Weight:75

For frequently recorded observations, create a template with your preferred or frequently used observations. Add the template to the progress note by clicking on Insert. Record the data as required.

Clicking on the icon at the bottom left of the progress notes will display the observations that the create observation from progress note feature has been configured for.

Edit Progress Notes

A progress note can be edited after creation, for the period of time configured in the Organisation Centre.
If you need to record additional progress note content, you have the following options:

  • Create a new note - click on New Note
  • Edit - selected from note Action menu; only available for the period of time configured in your organisation, allows you to edit the content and metadata attributes of the progress note.
  • Amend - selected from note Action menu, the progress note opens; only the privacy level and metadata attributes that have been configured as as editable can be modified - the note content itself cannot be edited.
  • Append - selected from note Action menu, new Append Note entry window opens, notes saved are added as additional notes under the original progress note
  • Mark as Written in Error - selected from note Action menu,

Each progress note in the history list has an action menu. Menu options display as per the following rules:

  • Note was written by you, within the organisation configured period of time that editing is allowed.

  • Note was written by you, outside of the organisation configured period of time that editing is allowed.

  • Note was written by another user:

Users with My Health Record access, in a patient record where My Health Record Access has been granted will also see an option to Upload to My Health Record to create an event summary.

Progress Note - written in error

Once a Progress Note has been added to a patient file, it cannot be removed.

If you have added a Progress Note to the incorrect patient record, you can select Mark as written in error on the Progress Note. You will be asked to provide a reason for striking through the note. The note will remain in the history as a removed note The note content will display, also struck-through, along with the date and time it was marked as entered in error and the written in error reason.

Episodes of Care

When a second or subsequent progress note is written by any user for a patient on the same day, there will be a prompt requesting the user indicate if this note is part of the same episode of care.
By default, yes and the episode of care start date/time will be selected; or a new episode of care.
If you choose to create a new Episode of Care, a new episode of care flagged for reporting purposes.

Progress Note Metadata

Organisations can define the progress note metadata or reporting fields that are visible to their users. The field names, content and positioning can be completely customised. Refer here for more information on configuring these fields.

The fields are important for organisation activity reporting.

When you start a progress note you may see a number of reporting fields, with additional fields visible when Show Additional Fields button is clicked. You will also see a notification if there are strongly recommended fields to be completed with your progress note.
You may also see a prompt to complete empty recommended fields when you click Close Patient if this has been configured by your organisation. You should return to your progress note, record the recommended data and then close the patient record.

Amend a Progress Note

If you saved a progress note without completing all recommended fields, and need to return to input the required data at a later date, locate the progress note and from the action menu, select Amend. The progress note will open with the entry field locked to prevent editing of the content, but with editable metadata fields visible. (A non-editable field will be greyed out and the cursor will display as a red icon if you hover over the field.
Enter the required data in the editable fields and click Update.

The Progress note will be updated with the metadata content, and will display the date and time that the fields were edited.

Review Progress Notes

Previous Progress Notes can be located in a list underneath the progress note entry field.
The progress notes will be displayed with the Date/Time, Event, Name (of Author), Location (organisation or clinic name), Role (of Author) of the note. The Progress Notes will display in chronological order, but each column can be sorted by clicking on the column heading to appear in alphabetical order.

The Event field will display information recorded in the metadata field that has been configured by your organisation to display here. For most organisations this will be a Reason for Contact type field.

All progress notes will be displayed in the preview window at the right side of the page by default. Select the note you wish to read and it will display at the right side of the screen and generate the scrollable list of progress note content; the list will include all notes including and older than the one you have selected to view.

Role is populated by the Primary Category applied to the user profile.
If no primary category has been applied, the content of the Qualifications field of the user profile will display.
For more information about categories read here and here.

Searching Progress Notes

Use the keyword search field to locate a specific note.
Keyword search looks at all columns and progress note content.

All notes that include that keyword will display in the progress notes list, with the content of a highlighted note displaying at the right side of the screen.

To clear a search, empty the search box and hit the Enter key.

Recent Patient Actions

Adjacent to the progress notes entry field you will see a display named Recent Patient Actions. This field displays recent activities, by all users, in the patient record and will display items such as:

  • Medications – archived, VTO, prescribed, dispensed, supplied and administered, DAA information
  • Forms completed
  • Observations
  • Radiology and Pathology referrals
  • Images
  • Consent
  • Clinical Handover Management Plans
  • Documents
  • Letters

The current business rule is that all actions, by any user, since the last progress note on that day (midnight to midnight) are displayed. Actions only appear in one progress note.

You may uncheck items to NOT include them in the progress note you are writing. The patient actions are recorded within progress notes that are created throughout the day.

The name of the user who completed the action and the time they completed it displays clearly to ensure that there is no suggestion that the progress note author completed those actions.

Displaying patient record related activity in this field enables you to see what activities other users are undertaking in the clinical record whilst you are also working in the patient file. It is a key support to multiple users being able to work in a clinical record simultaneously

manual/progress_notes.txt · Last modified: 2019/11/23 05:48 by sarahb