Clinical Notes is an optional feature. If you do not see Clinical Notes in your display options, it has not been enabled for your organization.
- Sort all documents on this list according to date, author, and note type.
- Pre-select one or more notes from the Clinical Notes list to include in your next NoteWriter note. To pre-select notes that you created in NoteWriter, they must be signed.
| Signed Notes | Draft Notes |
|---|---|
| Have no particular distinguishing characteristics to differentiate them from other documents on the Clinical Notes list. | Are identified by the term DRAFT, and use the Draft icon to differentiate them from other documents on the list. |
| Can be viewed by all providers belonging to the author’s department. | Can be viewed by their author only. Other providers do not see these notes until they are signed. |
| Cannot be edited by any user, including the note author. | Can be edited by their author only. |
| Cannot be deleted by any user, including the note author. | Can be deleted by their author only. |
- Select a patient on the Patient List tab, or click on the Details icon from another option.
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Click Clinical Notes from the display list. The patient data display area shows the Clinical Notes window that contains a list of the most recent clinical notes for the selected patient, including both text-based documents and scanned images of documents. It contains columns for Date/Time, Note Type, and Author.
If you are looking for a note that you do not see in the results list, click the Load More Data button at the bottom of the list. If additional notes exist, they are added to the bottom of the existing list. For information on loading more data, see Displaying More Clinical Notes Data.
Consult your Commure Pro representative if you would like to adjust the height of this window, to make it larger or smaller or to adjust the default number of results that are displayed. For scanned documents, the word “Scanned” precedes the description of the note type (for example, “Scanned: History and Physical”). In addition, the Author column 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. Your organization can suppress the Author column for scanned documents via an XML customization if they do not want the name of the scanner to show. If this customization is implemented, the Author column will be blank for scanned documents.
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You may change the order in which the Clinical Notes are sorted, by clicking on a heading. For example, clicking the Author field would sort the notes alphabetically by author. Clicking any column header a second time reverses the sort order.
If you click Load More Data the sort order is reset. Click a heading to sort the results again after loading more data into the list.
- You may filter the list of clinical notes, by types of note. To do so, click the drop-down filter located in the upper right corner of the Clinical Notes window. The various types of notes used by your institution are included in the filter list. Select items from the list to view only those types in the Clinical Notes window and then click OK. The drop-down filter will display as Filtered to indicate that you have chosen a subset of filters instead of All.
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You may change the order in which the Clinical Notes are sorted, by clicking on a heading. For example, clicking the Author field would sort the notes alphabetically by author. Clicking any column header a second time reverses the sort order.
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If you would like to see the details of a clinical note itself, simply click on that note in the summary list. The Clinical Notes detail window opens below the summary list, showing you the full contents of the note. The tools available on the detail window depend on whether the note is a text-based document or a scanned document.
- See Viewing the Details of a Text-Based Clinical Note for instructions on viewing the contents of a text-based document.
- See Viewing the Details of a Scanned Clinical Note for instructions on viewing the contents of a scanned document.
- (Optional) You may print the Summary or Detail window by clicking Print For details on printing in the display area, see the text describing Print icon in Understanding the Patient Data Display.
Displaying More Clinical Notes Data
The Clinical Notes window displays the most recent notes for the selected patient. If there are more notes to display, you can load them into the window until you see what you are looking for or until all of the available notes are displayed. The number of notes displayed at a time is based on the setting Number of Elements retrieved for “Load More” (Portal). This settings affects the number of notes that are initially displayed, and the number of additional notes displayed each time more data is loaded. You can refresh the list to reset it to the most recent notes by clicking Refresh . The most recent data is loaded when the list is refreshed. Consult your Commure Pro representative if you would like to adjust the default number of elements that are displayed. To display more data, follow these steps:- Scroll to the bottom of the Clinical Notes Summary list so that the Load More Data button is visible.
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Click the Load More Data button to check for more notes. If additional notes are available, they are loaded and added to the bottom of the list. If there are still more notes to display, the Load More Data button remains available at the bottom of the current list. Continue to click the Load More Data button until you find the data you are looking for or until all of the data is loaded. When all of the available data is available the Load More Data button is no longer available.
If any filters are applied, the Load More Data button is only visible when there are more notes to display that meet the filter criteria; if all of the notes meeting the filter criteria are displayed the button is not visible.
Viewing the Details of a Text-Based Clinical Note
To view the contents of a text-based clinical note, use the vertical scroll bars to move your view to the top or bottom of the document. Some reports may use a wide table or columnar format. In this case, a horizontal scroll bar allows you to move your view to the left or right in order to see the contents of a wide document.If MEDITECH® is your source system, the Commure Pro system derives clinical notes from three sources: departmental reports (medical records), nursing notes, and nursing interventions.
- You can use the Change Font icon to toggle between a fixed-width and variable-width font when viewing clinical notes. The fixed-width font preserves the formatting of the note and makes it easier to read text that uses a table or columnar format.
- You can use the Search field at the top of the window to find all instances of a particular word or phrase in the note. First type in the desired phrase, and then click Search (or press the Enter key on your keyboard). Click repeatedly on the icon to move to each subsequent occurrence of that word or phrase in the note. The search function only searches through the body of the selected note.
Viewing the Details of a Scanned Clinical Note
To view the details of a scanned document, you can use the vertical and horizontal scroll bars. There are also several controls at the top of the detail window that allow you to manipulate the scanned image for better viewing.- Use the controls at the top left of the detail window to reduce the document, fit the document to the window, or enlarge the document.
- Use the controls at the top center to go to the first page, previous page, next page, or last page of the document.
- Use the controls at the top right to rotate the document to the left, or rotate it to the right.
The Search field is not available for scanned documents.