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How to Write Clinical Notes?

Single Notes for Single-patient Consultations

Single Notes for Multi-patient Consultations

Multiple Notes for Single-patient Outpatient and Inpatient Consultations

Multiple notes for Multi-patient Outpatient Consultations

Clinical Note Types

Clinical Note Templates

Clinical Note Drafts

Editing Clinical Notes On Finalised Consultations

Unapproved Clinical Notes

Table of Settings That Control Clinical Note Functions

Introduction

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, and as such, it takes place on consultation pages.

Clinical note workflow has several customisation options so the appearance for your practice may vary - we'll start from the simple workflow in this guide and work our way through more complex solutions.

How to Write Clinical Notes?

Short instructions are as follows:

1. Go to the appropriate consultation page (your client and patient).
2. Scroll down until you see the 'Clinical notes' section.
3. Type the notes into the text field in that section. You may need to use a separate blue plus button to add a clinical note if the multiple clinical note workflow is enabled in your practice.
4. You can proceed with other tasks once you're done, the text is auto-saved.

Understanding Various Clinical Note Workflows

Single-note Workflows

Single Notes for Single-patient Consultations

Perhaps the simplest setup is where each consultation can have a single clinical note for each patient. This is also the default setup of Provet Cloud. For this workflow to be enabled, you need the department setting 'Multiple clinical notes for outpatients' to be disabled. Also, the workflow may be disabled if your practice uses Provet Cloud 'Hosptial mode', in which case, multiple notes are enabled for hospital inpatients.

On consultation pages, you'll find a section called 'Clinical notes':

• The section has a text field for writing clinical notes.
• The field can have a default note in it once you open a consultation. The default note can be customised or removed with the department setting 'Default clinical note'.
• The clinical note field can also be automatically filled with a clinical note template if the consultation reason is configured that way.
• You can also use clinical note templates manually by using the blue 'Text templates' option. The templates are configured from Settings > Items & Lists > Templates > Text templates.
• You can print clinical notes using the blue printer button.
• If the patient has clinical notes from previous consultations, you can use the 'Show previous clinical notes' button to see them.
• Note that below the text editing options, on the bottom right, there's a 'Last edit' info about the last user who edited the note. That info text can be clicked to see the full log about the note.
• Clinical notes are automatically saved.
• Note that you can't fully delete a clinical note.

Single Notes for Multi-patient Consultations

When you admit more than one patient to a consultation, you have the option to write notes that go to every patient's clinical history and fields for writing notes for selected patients specifically.

• In terms of general functionality, these notes work the same as described above.
• By default, the 'All patients' field is seen and writing text there creates an entry for all patients on that consultation.
• You can select specific patients from the right-hand sidebar by using the 'Select patient' drop-down menu. Note that another clinical note field opens for that patient as seen on the image below.

Multi-note Workflows

Multiple Notes for Single-patient Outpatient and Inpatient Consultations

As hinted above, there's a department setting 'Multiple clinical notes for outpatients' that generally controls whether a consultation can have a single clinical note for a patient or more. Also, the multiple note workflow is enabled if the hospital mode is enabled from department settings and the patient is marked as an inpatient.

If the multiple note workflow is enabled, you'll see a different, more complex clinical note section:

• There's a blue plus button for adding new clinical notes.
• You'll see existing clinical notes in a table format, with options to print and edit the notes using the buttons on the rows.
• The timestamps are clickable to show the editing log. They also show the creator's/editor's initials.
• As usual with tables in Provet Cloud, you have various filtering options and page controls.
• There's a department setting 'Open new clinical notes automatically' - when that's enabled, the program helps by opening the first clinical note for editing automatically when arriving at the consultation page.

When editing or creating a note, a separate editing section opens:

• The text field is generally the same as with the single note workflow.
• The text is auto-saved, but until saving manually with the green check button, the note is in a draft state, even if you have draft clinical notes disabled (see the setting described below).
• At this point, you can also delete the note with the white X button. This is not possible using the single note workflow - once you start typing there, the note is created and can't be fully deleted anymore.

Multiple notes for Multi-patient Outpatient Consultations

When you have the department setting 'Multiple clinical notes for outpatients' enabled and you have more than one patient in a consultation, you can use the multiple note workflow with them. In that case, the clinical note editing section has a patient selector like the one on the right sidebar (see image below).

• If you switch the patient from the right sidebar, the clinical note selection also changes, and also controls other features on the consultation page.
• If you switch from the clinical note editor, the general selection on the right sidebar stays as it was.

Clinical Note Types

As you may have noticed from above, clinical notes can also have types. These are meant for the optional categorisation of clinical notes. On consultations and in patient history, clinical notes can be filtered and sorted by type. This can be handy when there's input from several employees and the clinical cases are more complex.

• By default, all notes are of the 'General' type.
• Types can be added and customised with a list from Settings > Items & Lists > Lists.
• Types can be organisation-wide or department-specific.

Clinical Note Templates

As mentioned above, you can use clinical note templates which is a powerful way to speed up your workflow.

• Clinical note templates can be customised from Settings > Items & Lists > Templates.
• Clinical note templates are used throughout your organisation if you have more than one department (clinic) on your Provet Cloud account, but it's possible to 'Enable department-specific clinical note template types' from department settings.
• Reasons can define a clinical note template that's used automatically.

Clinical Note Drafts

Clinical notes can be in a draft state. This means that the data is recorded in the system, but by default, these notes do not appear in patient history when emailed or printed.

• Clinical notes can only be in a draft state when the multiple clinical note workflow is enabled.
• Clinical notes will be in the draft state automatically after auto-saving when somebody is writing them with the note editor open on the consultation page.
• Manual clinical note drafts can be enabled from department settings. When enabled, users have the option to manually save the clinical note as a draft when they purposefully want to delay publishing it in patient history (see the image below with an added button). Otherwise, saving a note without the draft workflow enabled immediately saves it as a regular note (not a draft).
• Consultations (consultation invoices) cannot be finalised with draft clinical notes by default. There's a department setting 'Allow finalising consultations with draft clinical notes' that allows working past that limitation.
• There's also a possibility to 'Create tasks of draft notes upon invoice finalization' with a department setting to make sure that users remember to finalise their drafts. The deadline for those tasks can also be defined with a separate setting.
• It's possible to still include draft notes in patient history with the 'Show clinical note drafts in patient history' department setting.

Editing Clinical Notes On Finalised Consultations

It's often the case that a vet still wants to either just finish or add some details to clinical notes on a consultation that's already finalised. By default, this is not meant to be done freely and there are settings that clinic managers can use to control these actions.

• 'Allow editing text entries of finalised consultations' - this department setting works in conjunction with the next described setting that allows defining a number of days. When enabled, adding or editing clinical or discharge notes on consultations is allowed. When disabled, it's still technically allowed, but the system asks for a reason when the user tries to add or edit a note.
• 'Consultation text entry editing limit' - Use this setting to define the number of days when the editing is possible as described in the previous setting.
• The system asks for a reason when editing finalised consultation text entries is disabled or the deadline has passed. See the image below. The reason is recorded in the note editing log.

Unapproved Clinical Notes

It's possible to enable what's called unapproved clinical notes. These are meant for a university clinic workflow where students, assistants, interns or others can initially write clinical notes or discharge instructions. The unapproved notes need to be then approved by a veterinarian role user who can edit and merge the notes to patient history as regular clinical notes.

• 'Enable unapproved clinical notes' department setting controls these functions.
• See detailed usage instructions from the Student Features article (not built yet).

Table of Settings That Control Clinical Note Functions

See Also

Understanding Discharge Notes

Student Features