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Single Clinical Note Per Patient in One Consultation
Multiple Clinical Notes Per Patient in One Consultation
Editing Clinical Notes On Finalised Consultations
Clinical Note Approval Workflow
Overview and Basic Functions
Clinical notes are the main way to record patient medical history in Provet Cloud. They are meant for internal use and communication between veterinary professionals.
Writing clinical notes is part of the general consultation workflow. You can add clinical notes on the consultation page, in the text field under Clinical notes (1). The text in the field is auto-saved. Depending on the settings, the clinical note field may also be pre-filled with a default note or a template used for the selected appointment reason.
If the patient has clinical notes from previous consultations, you can select Show previous clinical notes (2) to view them. The previous clinical notes are listed with links to the clinical note edit log and the related consultation page.
If clinical note templates have been defined for the department, you can select a template from Text templates (3). You can also create your own templates and edit templates assigned to you if you have the required rights. For more information about templates, see Creating and Editing Text Templates.
Other clinical note options and functionality depend on the clinical note workflow your clinic uses (single or multiple notes) and the related settings.
Single Clinical Note Per Patient in One Consultation
In the single-note setup, you can add one clinical note for a patient in one consultation. This is the Provet Cloud default setup. Single notes can be used in single- or multi-patient consultations.
Note that if your practice uses the Provet Cloud 'hospital mode', multiple notes are always enabled for hospital inpatients.
The latest version of the note is shown in the text field under Clinical notes. The timestamp link under the field shows the time of the last edit and the user who edited the note (1). Select the link to view the edit history of the note. To print the clinical note, select the print button (2) above the field.
Note that in the single-note workflow, you cannot delete clinical notes.
Single Notes in Multi-Patient Consultations
When you have more than one patient in one consultation, you can write notes that are saved to each patient's clinical history.
In multi-patient consultations, the All patients field (1) is shown by default under Clinical notes. Writing notes in this field creates an entry for all patients on the consultation.
If you want to write a note for a specific patient only, select the patient from the Select patient drop-down list (2) in the sidebar. Another clinical note field opens for the selected patient (3).
Each field has its own edit log which you can open from the link below the field.
Conflicts with Multiple Simultaneous Users
When more than one user is editing the same consultation page at the same time, the system shows a warning message. Always be careful when editing the same information at the same time with another user.
If another user is editing the same clinical note at the same time as you, Provet Cloud warns you about a clinical note conflict, showing your (local) version (1) of the note and the other user's (remote) version (2). If you want to include the other user's text in the clinical note, copy and paste it from the remote version to the local version and select Save local version (3).
Multiple Clinical Notes Per Patient in One Consultation
In this setup, you can add multiple clinical notes for a patient in one consultation. Multiple notes can be used in single- or multi-patient consultations. Multiple notes are also used when your practice uses the Provet cloud 'hospital mode' and the patient is marked as an inpatient.
Adding Multiple Clinical Notes
Depending on the settings, you may need to select the plus button (1) to open a field for adding a new clinical note. You can select the date and time (2) for the note, for example, if you add a note afterwards to a finalised consultation. However, note that the edit log of the note shows the actual date and time of the edit. From the type drop-down list (3), you can select a clinical note type for the note if clinical note types have been defined. The default note type is 'General'.
The text added to the clinical note field is auto-saved, but the note remains in the draft state (even when draft clinical notes are not enabled in the settings) until you save it manually using the check mark button (4). Before saving, you can delete the note using the X button (5).
Viewing Clinical Notes
Existing clinical notes are listed below the note field. The timestamp link (1) at the beginning of each row shows the time of the last edit and the user who edited it. You can select the link to view the edit history of the note. Using the buttons at the end of each row (2), you can print or edit the note.
You can use the filters and the text field to filter and search the list (3). To view the clinical notes of a specific clinical note type, select an option from the Type drop-down list (4).
To save your selected filters so that the same selections are applied the next time you view clinical notes, select the wrench tool button > Save filters. Note that the same selections are used on all consultation pages (5).
Multiple Notes in Multi-Patient Consultations
When multiple notes are used and you have more than one patient in a consultation, you can select a patient from the Select patient drop-down list in the sidebar (1) or from the Patient drop-down list in the clinical note editor (2). Note that when you switch the patient from the sidebar, all content on the consultation page changes to show only the selected patient's information. When you switch the patient from the clinical note editor, the selection only affects adding the new clinical note. If you select All, the clinical note is saved for all patients on the consultation.
Conflicts with Multiple Simultaneous Users
When more than one user is editing the same consultation page at the same time, the system shows a warning message. Always be careful when editing the same information at the same time with another user.
When multiple clinical notes are used and more than one user adds a new clinical note at the same time, the notes are saved separately in the clinical note list.
Draft Clinical Notes
When multiple notes are used, clinical notes can be saved as drafts if enabled in your system. Depending on the settings, draft clinical notes may not be shown in patient history when emailed or printed.
Clinical notes are auto-saved as drafts (1), but before you can add a new note, you must save the open note. You can either select the check mark button (2) to save the note as the final version or select the Save draft button (3) if you want to keep it as a draft.
Note that depending on the settings, it may not be possible to finalise a consultation invoice if the consultation has clinical notes in the draft state. If finalising with draft clinical notes is possible, an automatic task may be created for the user who added the note, the active user, or the supervising veterinarian to make sure that users remember to finalise their clinical note drafts.
Editing Clinical Notes On Finalised Consultations
After a consultation has been finalised, you may sometimes still want to finish or add some details to clinical notes. Clinical notes can be edited after a consultation has been finalised, but depending on the settings, you may be required to give a reason for editing a note. There may also be a time limit for how long clinical notes can be edited without giving a reason. The reason is recorded in the note editing log which you can open from the timestamp link under the note field (with single notes) or on the note row (with multiple notes).
Clinical Note Approval Workflow
It is possible to enable unapproved clinical notes for consultations. Unapproved clinical notes are typically used in university clinic workflows where, for example, students, assistants, and interns can write clinical notes which must be approved and further processed by a supervising veterinarian.
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