Clinical Notes at a Glance
The Clinical Notes module opens with a Summary list of clinical notes for the currently selected patient.- The module heading row displays the number of Clinical Notes for the patient, such as “Clinical Notes (4 of 4).” When you apply a filter, this line is updated. For example, “Clinical Notes (1 of 4)” indicates that one note out of four match the filter and are displayed on the list.
- The patient heading row shows the selected patient’s name, age, gender, location, code status, and an additional identifier such as DOB, MRN, or account/visit number. An asterisk after the code status indicates that there are additional comments. You can tap on this heading to go directly to the Patient Details module, where you can view the code status comments, as well as other details for the patient.
- Each line summarizes a note. It shows the Note Type (such as History and Physical, Consult, Consent, or Nursing Assessment), the Author, the Date, and the Status of the note. It may also show the Source of the clinical note (the hospital or practice from which it was derived).
- Your organization may provide access to traditional text-based clinical notes, as well as scanned clinical notes. From the Summary list, you can select either type of clinical note and read the details. The Clinical Note Detail screen opens and displays the text or scanned image for that note in a scrollable window. See Viewing the Details of Text-Based Clinical Notes or Viewing the Details of Scanned or PDF Clinical Notes.
Sorting Clinical Notes
You can sort the list of clinical notes by Date, Note Type, or Author.- From the Clinical Notes Summary list, tap More and choose Sort. The Sort screen is displayed.
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In the Sort By section, select the item by which you want to sort:
- Date sorts by date and time (most recent notes first, or oldest first).
- Type sorts alphabetically by note name (A-Z or Z-A).
- Author sorts alphabetically by the author’s last name (A-Z or Z-A).
- Select Ascending or Descending to specify the sort direction.
- Select OK.
Filtering the List of Clinical Notes
Use a filter to display a focused list of clinical notes for the selected patient. For example, you can filter the list to display one type of clinical note, such as Discharge notes. Each institution defines their own note types. The module header row keeps track of the number of notes currently displayed for the patient. For example, when no filter is applied, you might see “Clinical Notes (9 of 9)” in the header, and all of the available notes displayed in the summary list. If a filter is applied, the Filter button is displayed at the top of the summary list, with a label describing the filter criteria. For example, you might see “Clinical Notes (2 of 9)” in the module header, and the Filter button labeled, “Filtered by: Nursing” to indicate that only the Nursing notes are shown. If you apply more than one filter, the module header counts the combined number, and the Filter button label lists each of the filters that are applied. To use a filter for Clinical Notes, follow these steps:- Tap Filter in the upper right corner of the Clinical Notes Summary screen.
- Select or deselect one or more filters. If some but not all of the filters are selected, a Select All button is available at the bottom of the screen; tap Select All to select all of the available filters. If all of the filters are selected, a Deselect All button is available; tap Deselect All to deselect of the filters.
- Tap Done. The Clinical Notes Summary screen displays with the notes that match the filter criteria. The filter(s) remain selected until you choose something different.
To go back to showing all of the clinical notes for the patient
- From the Clinical Notes summary list, tap Filter in the top-right corner of the screen.
- At the bottom of the Filters screen, tap Select All, and then tap Done. All of the available notes are displayed in the Clinical Notes summary list.
Viewing the Details of Text-Based Clinical Notes
You can easily move between the Summary list of a patient’s clinical notes, and the Details screen that displays the details of the note. To review the details of a text-based clinical note, tap a note to select it. The Details screen opens and displays the text for that note. Use the swipe gesture to scroll up and down the page. From the Details screen you can:- Move to the Details screen for the next note in the patient’s Summary list. Swipe up or down to scroll through the Clinical Note and read the complete text. Swipe left or right to move to the next note in that direction; however, when viewing a note in Fixed Font swipe gestures to move to the next note are disabled.
- Go back to the Summary list and choose a different note. Tap the Back button at the top of your screen or on your device. For a clinical note that has a table format, preserving the column formatting is important so that the columns of data line up correctly. Fixed-width font is automatically selected when a clinical note has tables of data. If the report is just text, a variable-width font is used. Although in most cases you do not need to switch between the two, you can switch if necessary (see Using Fixed Font for Text-Based Clinical Notes).
Using Fixed Font for Text-Based Clinical Notes
When viewing a note on the Clinical Notes Detail screen, the application automatically uses a variable-width font for regular text, and a fixed-width font when there are tables of data. Fixed-width font uses mono-spacing to make the columns in tables line up correctly. You can switch between the two fonts at any time. To turn Fixed Font on or off, follow these steps:- From the Clinical Notes Summary list, select the note you want to review.
- From the Clinical Notes Details screen, tap More and choose Fixed Font. The note text changes to use the fixed font format. Swipe Left/Right to scroll to the side and read all of the information in Fixed Font.