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quick refView a Quick Reference on Viewing Clinical Notes Use the Clinical Notes module to review text-based or scanned clinical notes for the selected patient. The clinical notes are taken from your organization’s source system. Clinical notes can include Consult Notes, History & Physical, Nursing Assessments, Consent Forms, Discharge Summary, and Operative Notes.

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Clinical Notes at a Glance

The Clinical Notes module opens with a Summary list of clinical notes for the currently selected patient, with the most recent notes listed at the top.
  • The patient heading row shows the selected patient’s name, age, gender, location, and MRN. Use this information to verify that this is the right patient.
  • The module heading row displays the number of Clinical Notes for the patient, such as “Clinical Notes (4).” When you apply a filter, this line is updated and the Filter button displays at the top of the list. For example “Clinical Notes (2)” indicates that only two notes match the filter, and “Filtered by: Consult” indicates that only Consult note types are displayed.
  • Each line summarizes a note. It shows the Note Type (such as History and Physical, Consult, Consent, or Nursing Assessment), the Date of the note, the Author, and the note Status. 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.
  • If writing clinical notes on a device has been enabled for your user, you will also have access to mobile NoteWriter, where you can enter notes, save and edit drafts, and sign and submit your notes from the Commure Pro on Apple app. For more information about this, see Writing Clinical Notes.

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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)” 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)” 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:
  1. Tap Filter in the upper right corner of the Clinical Notes Summary screen. The Filters screen is displayed and shows the following:
    • The top of the screen displays a list of Filter Terms. The currently selected filter(s) are indicated by a checkmark.
    • Below the Filter Terms, you may see additional filters by Source (the hospital or practice from which the clinical note information was derived), if your organization has implemented the Health Information Exchange feature and it is enabled in your user profile. The currently selected filter(s) are indicated by a checkmark.
  2. Select or deselect one or more filters from the Filter Terms or Sources. 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.
  3. 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.

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To go back to showing all of the clinical notes for the patient

  1. From the Clinical Notes summary list, tap Filter in the top-right corner of the screen.
  2. 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.

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Viewing Clinical Notes Details

The Summary list displays a high-level status report of recent clinical notes, with each note summarized on a separate line. However, if you want to see more detail, 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. For any given clinical notes listed on the Summary, there is always a Detail screen that contains either a text-based report, or a report in a scanned or PDF format. The instructions for viewing both of these items are below:

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Viewing the Details of Text-Based Clinical Notes

To review the details of a text-based clinical note:
  1. From the Clinical Notes Summary screen, tap a note to select it. The Details screen opens and displays the text for that note. The top of the screen contains a heading with fields for Note Type, Date, and Status. The fields that are available depend on your source system. If your organization has implemented the Health Information Exchange feature and it is enabled in your user profile, you will also see a field for Source (the hospital or practice from which the clinical note information was derived).
  2. The body of the note is listed below the heading; scroll up and down the page to view the full text of the clinical note. 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.
From the Details screen you can:
  • Move to the Details screen for the next clinical note in the patient’s Summary list. Swipe right to left.
  • Move to the Details screen for the previous clinical note in the patient’s Summary list. Swipe left to right.
If a clinical note is displayed in fixed-width font, then when you swipe right or left, you go only to the left or right edge of the note. Tap Font to switch to variable-width font, and then you can swipe to the next or previous note.Font button
  • Go back to the Clinical Notes Summary. Tap Back .

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Using Fixed Font for Text-Based Clinical Notes

When viewing a text-based 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:
  1. From the Clinical Notes Summary list, select the note you want to review.
  2. From the Clinical Notes Details screen, tap Font in the top-right corner of the screen.
ClinicalNotes FixedFontBtn The font toggles between variable-width and fixed-width.

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Viewing the Details of Scanned or PDF Clinical Notes

If a clinical note is a PDF, or if it was scanned into your source system, you can view the document on your device. On the Summary list, scanned documents have the word “Scanned” preceding the description of the note type (for example, “Scanned: History and Physical”). In addition, the Author name shows the name of the person who scanned the document into the system, while the image of the document itself usually contains the true author. To view the details of a PDF or scanned clinical note, tap a note to select it. The Details screen opens and displays the document. On iPad™ devices, most or all of the image is shown. On iPhone® devices, only a portion of the image is shown at first, since the screen is smaller. On all devices, you can use the standard Apple gestures for zooming in or out (stretch or pinch), or you can scroll vertically or horizontally to focus on any portion of the note. If a single clinical note has more than one document (not page) linked to it, you can swipe left and right to alternate between documents.
If you are using Mobile NoteWriter, you cannot view scanned documents in the Clinical Notes module when pre-selection is turned on (instead, you will see the message “The selected note is a scanned document. Please disable pre-selection mode in order to view it.”). To turn off pre-selection, tap Settings > General, and then set Show Preselection to OFF.
From the Details screen you can:
  • Move to the Details screen for the next clinical note in the patient’s Summary list. Swipe right to left.
  • Move to the Details screen for the previous clinical note in the patient’s Summary list. Swipe left to right.
  • Go back to the Clinical Notes Summary. Tap Back . Settings that control this feature:Show Preselection