Adding Clinical Note Templates
Settings > General > Department > Settings
- Multiple clinical notes for outpatients and home calls: When this setting is selected, it is possible to add multiple clinical notes for an outpatient in one consultation. When the setting is not selected, only one clinical note can be added per patient in one consultation.
- Open new clinical notes automatically: This setting can be used when multiple clinical notes are enabled for consultations (see the previous setting). When selected, a new clinical note field opens automatically when opening a consultation page or saving a clinical note. When this setting is not selected, a new clinical note field can be opened from the plus button.
- Enable clinical note drafts: When this setting is selected, clinical notes can be saved manually as drafts.
- Show clinical note drafts in patient history: When this setting is selected, draft clinical notes are shown in patient history.
- Default clinical note: In this field, you can type a default clinical note text that is added to all new consultations unless a text is added from another source (for example, reason settings).
- Allow finalizing consultations with draft clinical notes: When this setting is selected, consultations can be finalised with draft clinical notes.
- Enable unapproved clinical notes: When this setting is selected, users with appropriate permissions can write unapproved clinical notes, and the notes can be approved or rejected by the consultation supervising user. 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. Only approved notes are shown in the patient history.
- Enable department specific clinical note template types: When this setting is selected, the template selection dialogue on the consultation page only shows those clinical note types in the note type filter list for which the active department has templates. For example, if Clinic A has templates for clinical note types 'Anamnesis', 'Triage', and 'Clinical examination' and Clinic B only has templates for 'Anamnesis' and 'Clinical examination', a user on Clinic B only sees clinical note types 'Anamnesis' and 'Clinical examination' in the note type list. If this setting is not selected, the user also sees clinical note type 'Triage' even though no templates are available for it.
- Allow editing text entries of finalized consultations: When this setting is selected, clinical notes can be added and edited on finalised consultations. When the setting is not selected, adding and editing clinical notes on finalised consultations is possible, but the system requires a reason when a user adds or edits a note.
- Consultation text entry editing limit: When the previous setting is selected, you can define the number of days clinical notes can be edited on finalised consultations.
Settings > General > Department > Task
- Create tasks of draft notes upon invoice finalization: When this setting is selected, a task is created automatically when an invoice is finalised for a consultation which includes draft clinical notes.
- Default assigned user for tasks about draft clinical notes: In this field, you can select the user who the task is assigned to: created user (the user who created the draft notes), active user (the user who finalised the invoice), or supervising veterinarian (the veterinarian responsible for the consultation).
- Deadline (in days) for draft note tasks: In this field, you can define how many days after invoice finalisation the task is due. Note that if you set the deadline as 0, a task is created with an immediate deadline when a draft clinical note is saved (not when the invoice is finalised).
Note: The following settings must also be enabled:
- Enable clinical note drafts
- Multiple clinical notes for outpatients and home calls
- Allow finalizing consultations with draft clinical notes
Settings > General > Department > Summary email
- Include clinical notes in history attachment: When this setting is selected, the clinical notes of the consultation are added to the patient history attachment in the consultation summary email.
User Group Permissions
Settings > Users > Permission groups
These settings control the availability of clinical note functionality for user permission groups:
- Can add clinical notes on consultation
- Can edit notes, discharge instructions and clinical notes made by other users
- Can always add / edit discharge instructions and clinical notes after consultation has been finalized
- Can add unapproved clinical notes on consultation
- Can see and edit clinical notes made by students
Adding Clinical Note Types
Clinical note types can be used to categorise clinical notes. On consultations and in patient history, clinical notes can be filtered and sorted by type. This can be useful when there is input from several employees and the clinical cases are more complex. By default, all notes are of the 'General' type. Clinical note types are available on consultations when the multiple notes workflow is used.
1. Create a list for clinical note types.
- Go to Settings > Items & Lists > Lists.
- Select + Add list.
- From the Type drop-down list, select Consultation note type.
- In the Name field, type a name for the list.
- Select Save. The empty list is added to the Items & Lists - Lists page.
To edit the list properties (type or name of the list) after saving, select the pen button on the list row.
2. Add clinical note types to the list.
- Select the list name (shown as a link) to open the list page.
- Select + Add item. The Create list item dialogue opens.
- In the Code field, you can add an optional code for the clinical note type. The code is for internal use and can be any identifier you want to use. If codes are used, they must be unique within the list.
- In the Label field, type the clinical note type name.
- In the Departments field, select the departments you want the clinical note type to be available for. By default, the clinical note type is available for all departments.
- Select Save.
To edit the code or label of a clinical note type after saving, select the pen button on the row. Note that you cannot edit a clinical note type if it has been used for clinical notes.
3. Activate the clinical note type list.
The clinical note type list has to be activated before the clinical note types can be used when writing clinical notes. Go to the Items & lists - Lists page, find the clinical note types list and select Activate on the list row.
Adding Clinical Note Templates
With clinical note templates, you can make adding clinical notes easier and faster for users. In appointment reason settings, you can also select a clinical note template that is automatically added to the consultation when the reason is used.
- Go to Settings > Items & Lists > Templates.
- Under Text templates, select + Add.
- From the Type drop-down list, select Clinical note template.
- From the Note type drop-down list, select the clinical note type you want this template to be available for. If you select nothing, the template is available for all clinical note types.
- Add a Title for the template and add the template text.
- From the User drop-down list, you can select a specific user who can edit the template (other users can only use it). If you do not select a user, only users with the rights to add and edit templates through the settings can edit the template.
- In the Departments field, select the departments you want the template to be available for. By default, the template is available for all departments.
To edit a template after saving, select the pen button on the row. For more information about creating text templates, see Creating and Editing Text Templates.
Setting Up Reason Groups and Appointment Reasons
Creating and Editing Text Templates
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