Adding a Clinical History Note

To add a Clinical History note:

1. Search for and select the patient.
2. Select the Clinical tab.
3. Under Clinical History, select Add.
   
   The Clinical Notes window appears. For more information, see Clinical Notes Window Overview.
4. From the Type dropdown, select the type of clinical note being added.
   
   • This is the only mandatory field.
5. Enter any additional information following the DAP (Data Assessment Plan) format.
6. Select OK. The Clinical Notes window closes.
7. Select Save.

Once a Clinical Note is saved to the Clinical tab, it can be opened in a read-only mode by selecting the Clinical Note and selecting Detail.

Next Steps

If a Patient Follow Up or Doctor Follow Up date was selected, an Activity is created in the Workbench > Activities Dashboard and should be actioned appropriately.

For more information see, Completing Activities.