Clinical notes – general information

To enter a patient’s clinical notes:

- Select the patient from the appointment book and press [Enter]; or
- Press the [Notes] button at the top of the screen; or
- Select Clinical Notes from the View menu.

Note: The second two options will then require you to search for the patient whose notes you wish to view.

An overview of the patient’s demographic information is displayed at the top of the screen. To correct any information, click on the patient’s name to move to the Patient Details screen. When you push [Finish], you will return to their Clinical Notes.

Correct the consultation date or user’s name as required in the fields at the top right of the screen. Select the site of consultation if this was not at the usual surgery site e.g. a Rest Home Visit.

The Family Members pane at the bottom left of the screen lists all family members who have been linked to this patient in the system. If, for example, the patient asks about another family member, or more than one member comes to the consultation, double click on the relevant member’s name to move to their Clinical Notes. The program will ask if you want to automatically create a Walk-in appointment for this person. The Clinical Notes of the original patient will remain open as a separate tab.

Note: Only when you have finished the entire consultation and press [Finish] or [Finish/POS] to exit the patient’s Clinical Notes will the program print any letters, forms, scripts etc. that you have created during that consultation.