Clinical notes form part of a patient's health record in Halaxy and can be accessed from their patient profile page. Clinical notes allow you to add additional information on a patient to provide better treatment. You can view a list of a patient's clinical notes in their profile.
Clinical notes can be created manually or automatically. A new clinical note is automatically added for every appointment, and clinical notes can be linked to an appointment and its associated invoice. Prescriptions, orders, clinical templates and clinical tools are also added as clinical notes to a patient's profile.
You can create a patient's clinical note in two ways:
From your calendar: click an appointment that has already been made, then click Notes to go to the clinical notes specific to that appointment; or
On their patient profile: click the Clinical page, then click New Clinical Note. This method is best used when there is no appointment associated with the clinical note. You can choose the type of clinical note that you are creating.
You can then begin entering your notes into the clinical note that you have created.
A patient's clinical notes are visible on the Clinical Notes tab on their patient profile. You can access the Clinical Notes tab in two ways:
From a patient's profile: go to the patient's profile from your Patients List, invoice or your calendar, then click the Clinical tab; or
From your Calendar: When an appointment has been made with the patient on your calendar, click the appointment on the calendar, then click Notes. You will be taken to the notes created for the specific appointment.
Practitioners with the appropriate level of access can also click the Social History tab on a patient's profile to view and edit their demographic background and details.
The Clinical Notes screen is structured so that you can see each of the patient's clinical notes on the left-hand side, with the current note that you are viewing in the centre.
On the left-hand column, click the Expand (+) icon next to "Update Note Filters" to access filters that you can use to search for clinical notes:
You can sort by Chronological or Reverse Chronological order, set From and To date filters, and filter by the type of Clinical Note.
Click Save to activate your filters.
Once you have created the clinical note (or once it has automatically been created for you), you can begin entering patient records, including case notes, letters, referrals, reports and assessments. Formatting your records is similar to formatting in Microsoft Word, and you can format text and paragraphs, move text, add tables and lines. You can also add images and dynamic terms, as well as select your preferred template.
For clinical notes attached to an appointment/invoice, you can add fees and edit invoice fee amounts while writing clinical notes. First click the down arrow next to the invoice number, then:
Changing the fee amount or details for this appointment: click the Edit icon next to the fee and make the changes required;
Adding another fee to the invoice for this appointment: click Add Fee, then select the fee that you want to add to the invoice (or add the fee to your Fee List here if it is a new fee) and click Save.
Deleting a fee: click the Delete icon next to the fee and confirm that you want to delete the fee.
Click the up arrow next to the invoice number to collapse the view.
Clinical notes are automatically saved as you type. You can also click Save at the top-right to manually save. Once saved, the status of a clinical note is recorded as Draft.
If your internet connection goes down or becomes very slow, you receive a notification telling you to manually save the note by clicking Save, as automatic saving may be affected.
You can publish a clinical note by clicking the small arrow to the right of the Save button and selecting Publish. Publishing converts dynamic text to the actual words - for example, [Patient given name] [Patient surname] becomes the patient's actual name (e.g. John Smith) when published. Once published, the note cannot be edited, allowing you to lock down the note.
If needed, you can revert a published clinical note back to Draft status to make changes. To revert a note, click the blue Revert button at the top-right of the published note, then click OK to confirm you want to revert the note to Draft status. Once reverted, you are able to make changes to the note.
To delete a clinical note (e.g. a case note, clinical report or letter), click the small arrow to the right of the Save button when a note is in Draft status. Select Delete from the drop-down menu and confirm that you want to delete the note. The note is then removed from the clinical note listings down the left-hand side.
You can only delete clinical notes that you own, and you cannot delete a clinical note if it has been published for longer than two weeks.
You can also delete a full patient profile on their General page.
You can print either a single patient clinical note or all the patient's clinical notes. There are two ways to print clinical notes:
By clicking the Print and Print Preview buttons at the top right of the screen, which prints a clinical note using your connected printer on your letterhead; and
By clicking the triangle next to the Save button and selecting Print - this is also how you print all of the patient's clinical notes.
When printing, you can:
Preview what clinical notes look like printed;
Print the clinical notes; and
Set your preferences for the format of printed clinical notes.
Click the cogwheel icon to set your default content and template preferences for printing clinical notes:
You can choose to print (a) just the contents of the clinical note; (b) the contents and appointment details or (c) the contents, appointment details and invoice details. You can also choose whether to include your header and footer on the note or not, or whether to include your header and footer on the first page only.
When you print a clinical note, dynamic terms are automatically converted to actual words - e.g. [Patient given name] [Patient surname] becomes the patient's actual name (e.g. John Smith) when it is printed.
If a clinical note is not already linked to a referral, from the clinical note, click the Edit icon next to the note title and select the relevant referral. When you save, the referral details are automatically populated for you when you print or preview the note.
You can attach a file to a clinical note by following the steps below:
From the clinical note, click Add Files.
Click Upload Files to select the file(s) from your computer, or click-and-drag the file into the area to upload it. You can upload up to 10 files at a time.
Select Clinical to limit access to the file to the patient's practitioner(s) and users with Clinical Access only. Select General/administrative to allow all users to access the file.
You can email the clinical note by clicking the triangle next to the blue button in the top-right, then selecting Email:
To include the attachment, click Add File in the Attachments section.
You may wish to use secure messaging to send sensitive information instead of email.