Progress Notes

Record notes about a patient's visit in Progress Notes.

The Progress notes section allows for data entry by any combination of typing, voice recognition, hand writing recognition, macro style fast auto text key in, where a few key strokes can result in a large amount of text being added, and finally, via series of system-specific History and Examination screens with options (check boxes) that translate into full text entries into the patient's Progress notes

All entries from these screens are internally coded, allowing for easy searching to find patients meeting specific requirements or presentations.
All clinical notes are stored in an encrypted form on the practice server hard disk drive, thereby preventing unauthorised back door access.

To manage a patient's Progress notes, in the Clinical window. select the Progress tab.
Progress note tab

Progress notes are divided into two sections:

The left-hand panel is where notes are recorded. Text can be typed directly in this area, and can be formatted by altering font, colour and appearance (bold, italics and underline) if required.
- Many notes are recorded here automatically by Clinical as you use its various tools, and notes are automatically saved when you leave a patient's record (provided this option is enabled).
- This area can be viewed as a mini, floating window that can be relocated and resized. This is also available via Patient > Floating Progress tab.
The right-hand (split) panel displays a history of Progress notes.
- The upper-half lists past Progress notes in order of visit, with the lower-half showing the detail of any selected past Progress note.
- This list also displays the current Progress note (the note you are actively working on), highlighted in green.
- When you open the patient's record, the latest recorded note is selected by default.
- During a consultation it is possible that newer notes display in this list periodically, placed after the note you are currently working on. This is because it is possible for multiple users to work on the same patient's record simultaneously, which means another user may save a note whilst you are still working on yours.

Each user can write a unique Progress note. You can modify your last note (created today) up until midnight. In restricted mode, most features on the Progress tab are disabled. However you can write notes, and access Comments and Management. You can resume your previous note (created today), provided you don't already have it open on another computer. Use shortcut keys to quickly add notes.

Table 1. Progress Notes Shortcut Keys
Shortcut key	Function
S:
O:	Objective
A:	Assessment
P:	Plan
Hx	History
OE	Examination
Dx	Reason for contact
Mx	Management

For more information, refer to Keyboard Shortcuts.

Progress notes are automatically saved at the end of the visit. If no notes have been recorded and no actions performed whilst in the patient's Progress notes, you will be prompted as to whether to save a record of their visit. When closing a patient's record, notes of the elapsed time are displayed, as well as the start and finish times are recorded in the database.

Table 2. Progress notes details
Field	Description
Consultation date	Allows you to select the date of consultation before you enter any notes. For example, you saw a patient last week, but forgot to enter any notes for that visit; by selecting the day on which their consultation took place, you can record notes for that day with the assurance that when saved, the notes will be listed correctly in order of visit date, not recording date.
Previous Visits	Filters the previous visits according to Reason for contact.
Visit type	From the Visit Type list you can indicate the type of visit for the day's consultation. The default visit type for practitioners is Surgery Consultation and the default for all other users is Practice Admin. You can add customised entries via the Lists tab of Clinical Options. You can set the default via the Progress Notes tab of Clinical Options. Your selected visit type for each consultation is also displayed in the past progress notes. When you close the patient's record, confirm the visit type you have selected. Both the drop-down list on the Progress tab and the associated prompt can be disabled via Progress Notes options.
Current Visit Box	This large text box to the left of the Progress window is where Progress notes for the current visit are recorded and displayed. Whilst it is possible to type text directly into this box, other notes are added automatically as a result of using the various components of Clinical. For example, printing a prescription generates an entry. Also the current date, time and practitioner name is entered by default for new notes.
Launch Floating Progress Window	Launches a mini, floating version of the Progress notes window that can be relocated and resized. This is also available via Patient > Floating Progress tab.
History	Display a series of tabbed pages to allow entry of an historical review. Each major system has its own page containing buttons and lists to enable the entry of symptoms without having to type.
Examination	Record examination findings using a combination of Yes/No controls, Check boxes, spin boxes, and Pick lists. Some areas enable you to draw on diagrams of sections of the body.
Reason	Enter a reason for the patient's visit or contact.
Review	Review a date or interval to be recorded in the notes.
Management	Add Management text. Management items are frequently used text that inserted using a shortcut key combination.
Comment	Enable user-defined blocks of text to be inserted at the current cursor position. A number of text blocks can be stored for each practitioner.
Procedure	Enter the details of any procedure performed on the patient into a Procedure section of the notes. It uses part of the DOCLE coded list that is also used elsewhere in Clinical.
Medicare	Associate a Medicare item number with a visit.
Append	Add any notes to the patients previous visits.
Diagrams	View any diagrams recorded during previous visits for the patient. Diagrams are entered through the Examination window. The Diagrams button is disabled if no diagrams have been recorded.
Search	Search the patient's previous progress notes for specified text entries.
Clear Search	Clear the search criteria.
Refresh	Refreshes the list of previous visits. If multiple users have the same patient's record open simultaneously, clicking this button will refresh your list to display any past notes saved by other users during this session.