Clinical Notes

Clinical Notes feature allows you to document discussions with a patient or information about a patient such as consultations, drug related problems, adherence, follow-ups and immunizations on a Patient Folder.

These clinical notes provide you the ability to link these notes directly to a prescription and document any data, assessment and plans that you've discussed with a patient.

If a follow-up is recommended based on these conversations, it can be scheduled directly from the Clinical Notes window and is automatically added to the Activities tile.

The information required for recording immunization varies slightly from other clinical notes. For more information, see Immunizations.

To learn more about recording clinical notes, select the applicable tab for your province.

In Alberta, clinical notes that are "EHR Professional Services" can be transmitted to the EHR. All other clinical notes remain local only. To learn more about adding EHR Professional Service clinical notes, refer to the Clinical History section of the Alberta RTI User Guide.

To learn more about adding local clinical notes, select the dropdowns below.

In British Columbia, clinical notes are not transmitted to the EHR.

To learn more about adding local clinical notes, select the dropdowns below.

In Saskatchewan, clinical notes are not transmitted to the EHR.

To learn more about adding local clinical notes, select the dropdowns below.

In Newfoundland and Labrador, clinical notes that are "EHR Professional Services" can be transmitted to the DIS. All other clinical notes remain local only. To learn more about adding EHR Professional Service clinical notes, refer to the Clinical History section of the Newfoundland and Labrador DIS User Guide.

To learn more about adding local clinical notes, select the dropdowns below.

In New Brunswick, clinical notes are not transmitted to the DIS.

To learn more about adding local clinical notes, select the dropdowns below.

In Nova Scotia, clinical notes that are "EHR Professional Services" can be transmitted to the DIS. All other clinical notes remain local only. To learn more about adding EHR Professional Service clinical notes, refer to the Clinical History section of the Nova Scotia DIS User Guide.

To learn more about adding local clinical notes, select the dropdowns below.

Select the dropdowns below to learn more about entering clinical notes.

Adding Clinical Notes

Clinical notes can be added from the following locations.

From Intake

To add clinical notes from Intake:

From the Workbench, Patient Profile, or Fax tile, select Intake.
Search for and select the patient, if they are not already entered.
Search for and select a drug.
Select the Clinical tab.
Select the Add Clinical Note button . The Clinical Notes window appears. For more information about this window, see the Clinical Notes Window Overview below.
From the Type dropdown, select the type of clinical note being added.
Optional - enter information into the remaining fields of the Clinical Notes window.
Select OK. The Clinical Notes window closes to the Intake window.

Once OK is selected, the clinical note cannot be edited.
- If a follow-up was scheduled under the Plan section, the follow-up is scheduled in the Activities tile for the day specified.
- The clinical note is saved to the Patient Folder Clinical tab.

From the Patient Folder

To add clinical notes from the Patient Folder:

Open the Patient Folder.
Select the Clinical tab.
Under Clinical History, select Add.

The Clinical Notes window appears. For more information about this window, see the Clinical Notes Window Overview below.
From the Type dropdown, select the type of clinical note being added.
Optional - enter information into the remaining fields of the Clinical Notes window.
Select OK. The Clinical Notes window closes to the Clinical tab.

Once OK is selected, the clinical note cannot be edited.
Select Save.
- If a follow-up was scheduled under the Plan section, the follow-up is scheduled in the Activities tile for the day specified.

Detailing Clinical Notes

Clinical notes can be detailed from the Patient Folder or Intake.

From Intake

To detail clinical notes from Intake:

From the Workbench, Patient Profile, or Fax tile, select Intake.
Search for and select the patient, if they are not already entered.
Search for and select a drug.
Select the Clinical tab.
Select the Clinical History button . The Clinical Notes window opens with a list of clinical notes entered in the Patient Folder.

Use the calendar controls at the top right to change the date range if needed.
- = displays the clinical notes completed today
- = opens the Calendar window with options to view clinical notes by day, week, or month
- = displays the clinical notes for the previous month
- = displays the clinical notes for the next month
The Filter can be used in combination with the calendar controls to filter clinical notes based on the text entered
To view additional details of a clinical note, select a record and then Detail. The clinical note will open in a read-only mode and cannot be edited.

Printing Clinical Notes

Clinical Notes can be printed by selecting the clinical note from Intake or the Patient Folder and then selecting the Print button. Dialogue notes cannot be printed.

From Intake

To print clinical notes from Intake:

From the Workbench, PatientProfile, or Fax tile, select Intake.
Search for and select the patient, if they are not already entered.
Search for and select a drug.
Select the Clinical tab.
Select the Clinical History button . The Clinical Notes window opens with a list of clinical notes entered in the Patient Folder.

Use the calendar controls at the top right to change the date range if needed.
- = displays the clinical notes completed today
- = opens the Calendar window with options to view clinical notes by day, week, or month
- = displays the clinical notes for the previous month
- = displays the clinical notes for the next month
The Filter can be used in combination with the calendar controls to filter clinical notes based on the text entered
Select a clinical note and then Print.

For a sample of the printed clinical note, click here.

Viewing Additional Clinical Notes

By default, Clinical Notes created in the last 90 days are displayed in the Patient Folder or from Intake.

To view additional Clinical Notes:

Open the Clinical Notes window from one of the following locations:
- From the Patient Folder, select the Clinical tab. In the Clinical History section, select the expander button .
- From Intake, select the Clinical tab and then the Clinical History button on the left.
The Clinical Notes window opens and displays the clinical notes for the last three months.
Optional: To modify the view, select the following:
- = displays the clinical notes completed today
- = opens the Calendar window with options to view clinical notes by day, week, or month
- = displays the clinical notes for the previous month
- = displays the clinical notes for the next month
The Filter can be used in combination with the calendar controls to filter clinical notes based on the text entered
Optional: Highlight the Clinical Note and select Detail to view more information or Print to print the note.

Dialogue records cannot be printed.
Select OK once done.

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