07 Creating a Medical Note

Medical Note: Overview

Medical notes, which use the medical note template, provide a great deal of flexibility for documentation. The medical note can be modified to include custom fields that capture identifying information, chief complaints, mental status assessments, etc. using note template customization tools.

• Note: note template customization is discussed in a different course.

The medical note is the only note template that includes a vital statistics tab. The vitals are one of the fields formatted to print to the medical note. The vitals can be directly added at this tab at the time the note is created or they may also pull in from the clients section if vitals are being maintained there. As long as the date of service on the vitals is a match to the date of service on the note, then the vitals will be displayed on the Vital Statistics tab.

Crating a Medical Note

This section of the course will guide you through the process of creating a medical note.

1. Click on Notes

2. Click on Add Note

• Helpful Hint: the system is being used to schedule services, then notes should be created from scheduled events. Doing so will ensure that the units flow correctly in the system and can be accurately counted.

3. Select the Client, Service Date, and Service from the drop-downs.

• Helpful Hint: The template field should auto-populate based on the service selected. If a medical note template does not auto-populate, open the drop-down and select this option.

4. Enter the Start Time and End Time (or Duration-if this is how time is captured for the particular service).

• Helpful Hint: Be sure to include am/pm.

Saving a Medical Note

5. The user logged into the system will auto-populate in the Caregiver field. The supervisor name will also auto-populate.

6. Click on the Save button to save the note

• Helpful Hint: Work on the note may be saved at any time.

7. After saving the note, the Vital Statistics tab will populate

• Helpful Hint: Vitals can be entered here or if they have been entered at the client record, they will auto-populate based on the date of service.

8. Finish the note by clicking on Sign Note

• Helpful Hint: Validation warning messages may be presented if there is anything systematically out of compliance with the note. You may or may not be able to override these validations depending on the settings for your individual role.

The DSM5 client diagnosis information and/or medications can be formatted to the medical note template. This is accomplished via request to support.

Example Validations

Example Medical Note w/ Diagnoses and Medications