Guide to clinical notes

Every patient health record on Halaxy stores clinical notes, which are used to document their medical history and care received over time. With your patient data stored in one place, you can easily track your patient's progress to provide treatment catered to their needs. 

Overview

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GIF: Creating an appointment automatically generates a clinical note (click image to expand)

On Halaxy, a blank clinical note is automatically created for every new appointment and linked to the appointment invoice.

You can also create notes manually and link them to specific appointments or referrals as needed.

Clinical notes can be used to create or store:

Tip

Want to save time? Set up clinical tools and note templates that you can use at every appointment!

View a patient's clinical notes

You can quickly access a patient’s clinical notes in two ways:

  • Open the patient’s profile and click the Clinical Notes tab. Select a clinical note from the list on the left panel to open it.

    Clinical-Notes-Guide-04.png
  • Open the patient’s appointment on the calendar, then click the Notes link. This opens the clinical note for this specific appointment.

    Clinical-Notes-Guide-05.png

Guide to the clinical note interface

In the Clinical Notes page, you can find the following:

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Image: The clinical note page interface (click image to expand)

  1. Patient name

  2. Note filters: A handy tool you can use to refine the list of clinical notes. To use filters, click Icon-Plus.svg plus icon to expand.

  3. List of clinical notes: The full list of all clinical records related to this patient. To open a clinical record, simply click on it from this list.

  4. Note information: Key information that is relevant to the clinical note. This includes the date, practitioner, location, linked appointment, linked invoice, and linked referral.

  5. Content: The details of the selected clinical note. This contains an editor where you can type up notes, reports, letters, referrals, or assessments. You can import templates for forms, assessments, or questionnaires. You can also attach files to any clinical note.

  6. Versions: A list of any versions you save for the selected clinical note. (Applicable only to notes.)

  7. Status: The state of the selected clinical note.

    • Draft / Published: Applies to notes and prescriptions.

    • Assigned / Completed: Applies to clinical tools.

  8. Option menu: A dropdown menu featuring a list of actions you can do with the selected clinical note.

  9. Quick action toolbar: A readily available selection of actions you can do with the selected clinical note.

Manually create a clinical note

  1. Open the patient's profile.

  2. Click the Clinical Notes tab.

  3. On the top right, click New Clinical Note.

  4. Fill out the clinical note contents.

This creates a standalone clinical note that is not linked to any other record on Halaxy.

Note

When an administrator creates a clinical note, they must select a practitioner to link to the note because it is not automatically assigned.

Edit clinical note information

  1. In the clinical note title bar, click the Icon-Edit.svg edit icon.

    Clinical-Notes-Guide-03.png
  2. In the pop-up, you can specify the following:

    • Title: Enter a label for this clinical note.

    • Date: Specify the date for this clinical note. This defaults to the appointment date. For manually created notes, the date defaults to the creation date.

    • Appointment: Select an appointment to link to this note.

    • Referral: Select a referral to link to this note.

    • Link to Clinical Note: Select an existing clinical note that is not linked to any appointment.

  3. Click Save.

Attach files to a clinical note

  1. Open the clinical note.

  2. Click Add Files.

    Clinical-Notes-Guide-02.png
  3. In the pop-up, click Upload File to select a file from your computer, or click and drag the file into the box.

  4. Click Save.

Guide to saving and publishing clinical notes

    • Clinical notes are automatically saved as you type.

    • To manually save a clinical note, click Save in the top right. When you save, the clinical note remains exactly as you left it when you return to it.

    • If your internet connection goes down or slows down, you receive a notification to manually save the note as automatic saving may be affected.

    • Whenever you manually save a note, the date and time of your last save is displayed under the clinical note status.

    • If you want to track changes for your clinical notes, you can save note versions that you can view or revert back to.

  • When you publish a clinical note:

    • The note status changes to Published.

    • The dynamic terms in the clinical note covert into the actual personalised words.

    • The clinical note locks and cannot be edited or deleted.

    • To publish a clinical note, click the down arrow next to the Save button, then click Publish.

    • You can revert the note back to Draft status by clicking Revert.

Delete a clinical note

You can only delete clinical notes that you created. You cannot delete a clinical note created by another practitioner.

  1. Open the clinical note.

  2. In the note, click the down arrow, then click Delete.

  3. In the pop-up, click Delete to confirm.

Note

Any clinical note in Draft status can be deleted. Publishing a clinical note locks it and prevents it from being edited or deleted. If you need to delete a Published note, you must first revert the note back to Draft status.

Updated

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