Home
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.
Medicare Benefits Schedule
Associate Medicare Item Numbers with a patient's visit in the Medicare Benefits Schedule window.
Add Item Numbers to a Patient's Progress Notes

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 .
  - Examinations
    Record the findings of a single consultation.
  - History
    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.
    - Add Item Numbers to a Patient's Progress Notes
  - 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.
- Examinations
- 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 formatted 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.

Add Item Numbers to a Patient's Progress Notes

Before you begin

A practitioner can add Medicare Item Numbers to a patient's Progress Notes during a consultation if required.

Procedure

To add item numbers to a progress note:

Select the Progress tab in the patient's clinical record.
Click Medicare. The Medicare Benefits Schedule window appears.
Select an item and click Add Item No to visit or double-click an item in the list.
To locate a particular Item Number, either:
- Enter the Item Number into the Go to Item No field
- Manually scroll through the list of items
- Enter a keyword into the field provided at the upper-right of the window and click Text search. Repeated clicking of this button jumps to the next item containing the search text. Show the full text description of an item by selecting an item from the list.
Click Save to save the items to the patient's record (including progress notes).

Results

Once the item has been added to the patient's Progress Notes, you can also enter the type of billing to be applied to the item. For example, Bulk Bill in the example below.

What to do next

If integrated with Pracsoft, this information will be transferred to the Billing Type column of the Pracsoft Waiting Room.

The information can also be fed back to the MedicalDirector Pracsoft Consultation Viewer or a third-party billing package using Clinical's VISITS.OUT file. There is also provision for the entry of Notes/Comments on this window. Notes entered here are also saved to the VISITS.OUT file.