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Clinical Management
Use Clinical to record your consultations with a patient and their clinical details.
Progress Notes
Record notes about a patient's visit in Progress Notes.
Procedures in Progress Notes
Add details of any procedures performed on the patient during a consultation to a Progress Note.

Clinical Management
Use Clinical to record your consultations with a patient and their clinical details.
- Actions
  An Action is a record of something that was done or is to be done for a patient.
- Progress Notes
  Record notes about a patient's visit in Progress Notes.
  - Comments
    A comment is frequently used text that you can insert into Progress tab using a shortcut key combination.
  - Diagrams
    To more accurately display conditions or procedures, draw on preset clinical images .
  - Examination Module
    Record the findings of a single consultation.
  - History Module
    Record a patient's clinical history and symptoms that have become evident since the patient's last consultation.
  - Management
    Similar to comments, use management items to insert frequently used text into a progress note.
  - Editing Previous Progress Notes
    Edit Progress Notes on the day they are recorded.
  - Medicare Benefits Schedule
    Associate Medicare Item Numbers with a patient's visit in the Medicare Benefits Schedule window.
  - Procedures in Progress Notes
    Add details of any procedures performed on the patient during a consultation to a Progress Note.
  - Reason for Contact
    Add a reason for contact or diagnosis to a Progress Note.
  - Review Notifications
    Add a Progress Note review notification as a recall or as text within the Progress Note itself.
  - Options Available on All Tabs
    Use these options on any tab of the Progress Notes.
- Prescribing
  Use Prescribing to prescribe medications to your patient, conforming with all requirements and regulations.
- Recalls
  A recall is a type of flag recorded against a patient's record to inform practitioners or practice staff of when a patient is due to return to the practice, usually so that some clinical procedure can be performed.
- Patient's Medical History
  History includes a patient's medical conditions, both active and inactive.
- Investigations
- Immunisations
  Use the Imm. tab to manage a patient's immunisations.
- Preventive Health
  The Preventive Health module provides assistance in identifying and preventing issues and potential problems by making suggestions or recommending actions.
- Assessments
- Cervical Screening
- Obstetrics Module
- Diabetes Module
- Summaries
  Clinical provides ormatted summaries which can be printed for patients.
- Measurements
  The Clinical measurements window displays the history of a patient's various clinical measurements.
- MedicalDirector Care
  Create Care Plans in MedicalDirector.
- Telehealth
  Consult with patients remotely.
- Honeysuckle Health Private Health Insurance Checker
- Tools
- Surgical Audit Tool
  Use the Surgical Audit Tool to record information about surgical procedures.

Procedures in Progress Notes

Add details of any procedures performed on the patient during a consultation to a Progress Note.

Before you begin

The Procedure module uses a subset of the DOCLE coded list.

Procedure

Select the Progress tab in the patient's clinical record.
Click Procedure. The Procedure window appears.
Enter the first few letters of the procedure name in the Pick from list (coded) text box. Procedures that start with the letters entered are displayed. The list of procedures changes dynamically as text characters are entered or deleted.
Double-click the required item from the list. Alternatively you can select from previous procedures or conditions listed in the Existing Past Medical History Items list, or free-type a procedure into the Free Text (uncoded) text box.
By default, the procedure is marked as active. To change this, deselect Active.
Select Left, Right or both to describe whether the procedure is for the left, right or both sides.
By default, the record is saved in the Past Medical History list and as the primary Reason for visit. To change these options, deselect Save in Past Medical History and Save as reason for contact.
To list this procedure on printed letters and summaries, select Summary.
To mark this procedure as confidential, select Confidential.
Click OK to confirm your selections.

Results

The information is saved to the Procedure section of the patient's progress notes.