Adding a consultation note

The program displays recent consultations, problems and outstanding tasks.

You can enter clinical notes into the designated text areas. These include areas for presenting complaint, history, examination findings, a working diagnosis and a list of actions taken. This corresponds to the problem orientated note format (S.O.A.P for Subjective, Objective, Assessment, Plan).

Beside the Add Complaint button, two indicators will appear if relevant. The left hand indicator tells you how long you have spent with this patient so far. The right hand indicator tells you how many other patients are in the waiting room. These will be updated every minute.

1. In the central tab, in the Presenting Complain field, enter the patient’s reason for attending.

2. Press [F3] or click in the History field and enter the full history of the current complaint.

3. Press [F4] or click in the Exam field and enter your examination findings.

4. Press [F5] or click in the Diagnosis field and enter a working diagnosis. Press [Enter] to search for the disease code for the diagnosis. Select the correct search result. The program will automatically enter the diagnosis label and code into the two fields.

5. Press [F6] or click in the Action field and type in any action taken, advice given, procedures carried out or follow up requirements. Press [Enter] to add it to the actions list which appears in the box below. Enter as many actions as required. To remove an action, right click it and select Delete or highlight it and press [Delete].

6. If there is more than one complaint, they are displayed as tabs, with the current complaint displayed as the foremost tab. To add another complaint, press [+] and in the same way enter notes about that problem or complaint. Click on any tab to move to that complaint. Create as many complaints as required.

7. Remove complaints and the associated notes by pressing [X].

8. If you wish to use a visual aid, press [Diagram]. Choose one from the list. You can now view the diagram. If it has come up in Microsoft Paint, you can then draw on the diagram and those changes will saved into the notes.

9. When prompted enter a discription of the diagram. The diagram will be listed in the box below. Note: To set up your computer to open these sorts of files in a drawing program (to allow you to mark the diagrams), in Windows, open My Computer. Select Folder Options from the Tools menu. Move to the File Types tab. From the list of file types, highlight BMP File and press [Change]. Highlight Paint or any other painting program you like and press [OK]. Press [Close] and then quit out of My Computer.

10. If you wish to attach a file to these notes, press [Attachment]. Select the file. When prompted, enter a description of the attachment. The attachment will be recorded in the box below. The file will be saved into the My Practice database, so the original file is no longer required. To view the attachment, double click on it in the list. Note: You can attach any type of Windows file to this patient’s record. Examples are digital pictures, ultrasounds or radiology files you receive, ECG, Spirometry, Word or PDF documents. The My Practice will use whatever program is associated with that file type to open it.

11. Press [F12] or [Finish] to end the consultation.

12. Alternatively, you can now enter service information into the Point of Sale screen as you exit the patient’s notes. To do this, press [Finish/POS] to end the consultation and move to the POS screen.

13. When you press [Finish] or [Finish/POS], the program will print any letters, forms, scripts etc. that you have created (see below).