Clinical Notes and Templates

Clinical Notes and Templates

Your clinical notes are very important in order to establish what procedures have been completed, what procedures you may recommend for the future or documenting modifications in treatment for a specific patient.

Once you have created a patient chart, you can begin to log in entries to the patient’s record. Once you have opened the patient chart, notice at the bottom of the page is the icon labeled clinical notes. Click on this icon and white space will appear where you can begin entering information. Click on the first icon to the left to enter the date, then you can enter personalized notes.

Another option is to enter a preset entry from the template selection. The collapsible panels to the right offer preset entries that you can use to log in data. Click on the appropriate category. Double click on the entry that applies to your situation. This will post an entry to the patient’s clinical notes. This preset entry can also be modified to suit your individual needs.

In addition to using preset templates for entries, you can also create your own template. Supposed you have a set format for creating your own personal notes, then you can create a template tailored to your needs.

First click on the far right icon – which is the template set up icon. Highlight the category under which you want to create a new template. Then select New Template. A new text box will appear. Name your template in the upper right corner of the text box. Then in the Clinical Notes Text area; begin entering your data. Once you have entered all your data. Click ok.

Your new template will be added to the collapsible panel list. Double click on your template title and your new entry will be inserted into the clinical notes area. You can add to or modified this entry to your preference.