This section deals with consultation notes. How to create, edit and delete them and how they link to other functionalities.
This video will show you how to create consultation notes for a patient:
How do you create a new consultation?
To write new consultation notes, go into the patient record, click "Consultations" on the left hand side and click the blue button "Write notes":
Should you have consultation templates you have previously created, click "Free notes" on the right hand side and select from your saved templates which will appear in the drop down menu. You can also add additional sections to this like below.
If using the standard consultation form "Free notes", you can choose from the categories listed (blue bubbles as circled below). You can choose from several sections from "Allergies", "Presenting Complaint", "Products", "Social", "Medication" and many more.
- Once you click on the bubble, it will appear as a full section. Below I've created an example with "Allergy":
Many of these sections integrate with SNOMED and MIMS.
Click on "Save" when done. Ensure you delete any sections of the consultation you do not fill in, by clicking "Delete record" under the sections box on the right hand side. Otherwise the consultation notes will not be able to save:
How do you edit, print and delete a consultation?
If you are the author of a consultation note, you can either edit or delete it. Anyone with access to the patient file can open/print it.
To edit, print (this will create a PDF) or delete the consultation, click the downward facing arrow near "Doctor Consultation 10/09/2019" for example as below:
How do you create consultation templates?
Click the "Settings" tab at the top of the page on the far right and click "Consultation templates" :
Click the blue "New template" button to create a new consultation template. You can add sections, choose the type of questions and name the template, click "Save" when complete, that will now appear under the "Free notes" menu as above when writing a new consultation:
How do you allow someone else to edit/create consultations?
You may want another user to be able to edit/write a consultation on your behalf.
To do this click "Settings", then "Medical settings" then tick the section which is circled below:
Now go to "Settings" and "Users", select the user for whom you would like to allow others to write/edit consultations on their behalf and scroll down till you see the section circled below, toggle this to "Yes":
To create a consultation in someone else's name click "Patients" then select the patient you would like and click "Consultations", then write notes as below:
Fill this in as required. At the bottom you will see the section as circled below, this will allow you to select which practitioner name you would like to use:
Once you select the practitioner click "Save", In this case, although I am signed in as "Charlotte Tidd" I have written this consultation as "Chris Hoy":