Learning more about the current clinical note - Case study

You will find below an explanation about how this feature works and some examples that could be particularly useful to you.

The current clinical note

All actions taken for a patient by a caregiver or someone who has the right to act on his behalf are saved in the patient’s record as a new note.

This note takes a special status as the "current clinical note" when saved. If the caregiver or its representative goes back in the patient’s record later in the same day, a yellow box will appear warning him that there is a clinical note in progress. The note can be retrieved by clicking on the yellow recovery icon.

At any time if the current clinical note is not retrieved on the same day or if a new note if started for the same patient, the note will lose its special status. It will then be possible to modify the note as usual by going to the List of clinical notes.

Case study

Case #1 - Addition of a comment and a task related to a laboratory result

  1. The physician logs into the EMR and goes into its Results module.
  2. He adds a comment on a blood sugar result.
  3. He then adds a task from the result so that the patient is called to make an appointment with the nutritionist.
  4. The physician archives the result.
  5. Later, the physician goes into the patient’s record.
  6. He sees that a warning message saying that there is a note in progress appears in the record (since the actions taken on a result generate a clinical note).
  7. He clicks on the recovery icon in order to add more information to the note.
  8. When opening the current note, the physician sees that the three actions taken earlier (the comment, the task, and archiving) appear in the note. He will be able to find all actions taken for that specific result in the same note.
  9. From now on, all actions taken for a patient are added to the current clinical note (even if the action is taken outside of the patient’s record, such as when archiving results or reviewing tasks).
  10. He adds a title to his note, a note tag, consultation details, and a conclusion.
  11. He clicks on Complete and at this moment, the note loses the "current" status. The note can be retrieved in the List of clinical notes of the patient's record.

ℹ️ Please note

  • All actions taken in relation to a patient are automatically added to the current note (whether an action in the Results or the Tasks modules, on clinical entities, etc.).
  • The addition of a title, of consultation details, or of a conclusion makes the note available via the List of clinical notes section of the patient's record. If none of these fields is completed, the note will be behind the eye.

    Case #2 - Addition of a vital sign and the consultation reason by the nurse before a consultation

    1. The nurse logs into the EMR and takes the mandate of a physician in order to be able to take action in a patient’s record.
    2. She meets the patient to take his vital signs and to learn about why he needs to meet the physician (she adds clinical items such as the temperature, pressure and adds a title as well as some details to the clinical note).
    3. She saves the note.
    4. The physician (in the name of who the nurse took the actions) goes into the patient’s record.
    5. He sees that a warning message saying that there is a note in progress appears in the record.
    6. He clicks on the recovery icon. He is now able to see and complete the note started by the nurse.

    Case #3 - Addition of personal history by the secretary

    1. The secretary, with the mandate of the physician, adds a personal history to the patient’s record. As a result, a new note is started in the record.
    2. As long as the secretary stays in the patient’s record, the addition of new personal histories or other clinical items will be saved in the same note.
    3. When the secretary leaves the patient’s record, the note remains active as the current clinical note.
    4. When she or the physician returns to the record later that day, a yellow warning message appears mentioning that there is a note in progress.
    5. As there are no consultation reasons, details, or conclusion, the clinical note will not appear directly in the List of clinical notes. It could be found by clicking on the eye icon.
    6. The secretary or the physician can continue to write the note by clicking on the recovery icon.
    7. If a note in progress is not retrieved and a new note is started, the new note will then take the status of the current clinical note. The note that was in progress and has not been retrieved will be available in the List of clinical notes.
    8. The note’s action logs are available at the bottom of the note. Therefore, it is possible to see that the patient’s personal histories have been added by the secretary and have been completed by the physician.