Adding a consultation note

The Clinical Notes Screen

The clinical notes screen presents a SOAP template for you to enter consultation notes
You will see information around this central SOAP area that will provide context to this consultation

The patient’s name and an overview of their demographic information appears at the top
The problem list and risk factors are shown on the left (patient profile)
Tasks (screening and recall jobs) appear on the right.
The lower part of the screen displays a summary view of the patient’s recent encounters.
The patients Medications and allergies can be included alongside the profile.

The time elapsed tells you how long you have spent with this patient so far.

A count of the patients waiting for you is updated every minute.

Problem Orientated SOAP notes

The presenting complaint

Record the patients main reason for attending

History

Enter the subjective history as obtained from the patient here

Examination

Enter the objective findings of your examination here.
Press F7 to enter measurements such as Blood Pressure, Weight, Height ….

Diagnosis

Enter your working diagnosis or assessment here
- Press [Enter] to code this diagnosis
- Press [Tab] to skip the coding

Change the colour of the diagnosis by using the colour drop down
To control who can see or edit this diagnosis, set the security level in the dropdown next to the diagnosis code
- Author: Only visible to the original author
- Profession: visible to those with the same profession as the author
- Organisation: visible to those in the same organisation as the author.
- Private items are not included in referrals
- Hidden are not visible to casual on-lookers

Differential

Use this area to record other differential diagnoses being considered or ruled out. Click on the Differential link for suggestions for common symptoms.

Actions

(select left radio button)

Type suggested actions or advice here then press [Enter]
Enter as many actions as required.
To remove an action, right click it and select Delete

Plan

(select right radio button)

Record actions to be considered in the future here

Handing multiple separate problems

To add another problem, click on the [+Add] tab
Enter another SOAP note as above
Return to any tab as required.
Remove Problems and the associated notes by pressing the [X] on that tab.

Include a diagram or an attachment

Draw on diagrams

Click on the diagram link under the actions list
Select from a list of templates with a BMP ending. (Popular diagrams include “Body Maps”, “Eye”,”Ear”)
Mark and annotate your diagram with Paint Tool
Close Paint and choose Save Changes, providing a meaningful name .

You will be able to see in diagram in the saved notes and in the list of attachments.

Display educational diagrams

Click on the diagram link under the actions list
Select from a list of diagrams with a JPG or PNG ending.
Close the picture tool when finished

Add an attachment

Click on the attachment link
Select a file from your computer or drive
Update the filename when prompted

You will be able to see the attachment in the saved notes and in the list of attachments.

You can attach any type of Windows file to this patient’s record, including ultrasounds or audiology files you receive, ECG, Spirometry, Word or PDF documents.

The original file will no longer be needed because when you attach a file it will be saved to the MyPractice database.

Using Assist

Click on Assist to see a list of websites that can help you make a diagnosis , get advice on treatment or educate your patient.

When you select a resource, it will open a website in a new tab.

The current diagnosis will be used to Search that website.

These websites do not require subscriptions
Click on the email button to send the website link to your patient
Click on the Print button to print the website.
Click on the PDF button to create a file of the webpage

The Family Notebook provides up to date information in an easy to read note format
The Merck Manual provides comprehensive documentation
The Patient UK (NHS) provides great handouts for your patients
The Smart Imagebase has pictures or videos on almost any condition
MD Calc provides calculators and scoring templates
Google Translate will find words in most languages
Google search for Medical authorities – filters the sites professionally

Further sites are accessible in your resources list in the Forms Tab

Finishing the Consultation

When you are finished writing notes, review any overdue tasks then

Click on Finish to save changes and print or send your forms and documents.
Click on Finish + Bill to save changes and print or send your forms and documents then open the Billing screen.