Recording Consult Notes

Brief Overview

There are two types of consults that can be recorded in Clinic to Cloud. A regular consult, as discussed within this article, is a consult that is conducted from a scheduled appointment.

You may also record consult notes and perform clinical actions without an appointment through creating a Quick Consult. The Quick Consult process is recorded within this article

 

Short Version

  • Double click on a patient's appointment to open a new consult.  
  • Record any notes and perform any required clinical actions.
  • Click Finish Consult
  • Enter any relevant billing information into the Message to Reception window.
  • Click Save & Close

 

Instructions

1. Double click on a patient's appointment in the Scheduler

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2. This will begin the consult counter in the top-right of the clinical window. 

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3. Depending on your settings, the clinical window may have either opened to the Clinical Journey or the Current Consult tab. If you are in the Clinical Journey, click on the Current Consult tab. 

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A) If you would like to change your default clinical screen, open Settings > My Settings.

B) Open the User Settings tab, and tick/untick the Use Clinical Journey List View as Default Tab for Consult option. 

4. The options that are available for you in the consult screen can be customised according to your needs. Please visit this article for instructions on how to customise your consult window. 

 

5. Notes may be free-typed into any of the four provided consult fields. You need only enter text into one of these fields as a minimum.

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Note: These fields can be automatically pulled into a letter if their appropriate Tags have been added to the letter template. 

 

6. The Plus + icons can be used to add items to your dictionary. Adding items to your dictionary saves you needing to type commonly used phrases, terms or paragraphs by adding them as macros. You simply need to add an item to the dictionary, type the first few letters into a consult box, and then click, or use Tab or Enter on your keyboard to select the macro you'd like to use. Watch the gif below to see how this works in action. 

Using_dictionary.gif

 

7. The Background Information and Previous Issues/Procedures fields are text fields that are visible in every consultation. You can use these fields to record information you would like to be on view at all times while in the patient record. Using the arrow in the corner allows you to hide the pane if required. 

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Note: These fields can be automatically pulled into a letter if their appropriate Tags have been added to the letter template. 

 

8. Allergies can be entered manually into the Allergies field, or you may select an allergy from the database. 

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Note: This field can be automatically pulled into a letter if its appropriate Tag has been added to the letter template. 

 

9. Patient Ethnicity can be recorded if you have this option enabled in your Consult Settings.

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10. Health Status is another option you may enable in your Consult Settings, that allows you to record information such as a patient's smoking, nutrition, alcohol and physical activity status. Click the Edit button to adjust this information. 

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11. At any time, the blue pane containing the Background Information, Previous Issues/Procedures, Allergies, Ethnicity, and Health Status fields can be collapsed to allow more viewing area, using the arrow. 

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12. Once you have recorded your consult notes, you may wish to complete one of the following actions as a part of the consult:

A) Create an Imaging Request

B) Create a Pathology Request

C) Prescribe Medication

D) Record Vital Measurements

E) Create a Letter

F) Add a Document

G) Complete a Clinical Checklist

H) Create an Operation Report

I) Add a WorkCover Certificate of Capacity

 

13. When you have finalised all you needed to complete for the consultation, click on Finish Consult

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14. The Message to Reception window will then open for you to communicate any billing requirements with your administrative staff. 

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A) Type of Patient - Allows you to record whether the invoice is for out-patient or in-patient services.

B) Type of Invoice - Controls how the patient should be billed for this item. 

C) Search for Billing Items - You may either use the search box to search for an item number, or the Search by Description button to search using keywords.

D) Select Favourite Item - If your Favourite Items have been configured in your Provider Settings, then you may quickly select an item for billing from this quick list. 

E) Item Details - Allows you to choose the price for the item you have selected.

F) Item Note - Allows you to record an in-line note about the billing item.

G) Message to Receptionist - Type a message to your administrative staff here, which will be saved against the appointment, and visible in the Scheduler (such as book in 4 weeks). 

H) Message to Receptionist Dictionary - Add items to your dictionary here, which allows you to quickly select a message to send to reception.

I) Send & Close - If you have finished all you need to for this consultation, you can click Save & Close to close the consultation window.

J) Send & Stay - Transmits the billing information and message for reception to your administrative staff, but will allow you to remain in the clinical file. This can be useful if you have not yet completed your notes.

K) Save as Favourite - You may template this window by entering all of the messages and billing information as you would like, and then click the Save as Favourite button. This information can then be easily recalled, saving you time from entering similar information again in future. 

L) Use Favourite - When you return to the window after saving a favourite, you can select the template from this drop-down menu to auto-populate the information

M) Invoice History -  Directs you to the patient's Invoice History so you may review any recent invoices. 

 

 

Further Reading

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