Forms & Reports
Content coming soon
Content coming soon
With a patient record open, select the Clinical Summary page, where there will be a section to add and review Progress Notes:
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:
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.
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:
Each progress note in the history list has an action menu. Menu options display as per the following rules:
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.
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.
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.
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.
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.
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.
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:
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