This article explains how to configure and use the different settings for clinical notes in Provet. You can set up clinical note types and templates to standardise your clinic's documentation and streamline your workflow.
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Multiple clinical notes for outpatients and home calls: When this setting is selected, it is possible to add multiple clinical notes for an outpatient in one consultation. When the setting is not selected, only one clinical note can be added per patient in one consultation.
When enabled, this setting also allows users to create, edit, or update notes on behalf of another professional. For instance, a nurse can enter notes for a veterinarian. Provet preserves a clear audit trail of both the responsible person (the owner of the note) and the actual author or editor (the user who entered or modified the note).
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Open new clinical notes automatically: This setting can be used when multiple clinical notes are enabled for consultations (see the previous setting). When selected, a new clinical note field opens automatically when opening a consultation page or saving a clinical note. When this setting is not selected, a new clinical note field can be opened from the plus button.
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Show clinical note drafts in patient history: When this setting is selected, draft clinical notes are shown in patient history.
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Default clinical note: In this field, you can type a default clinical note text that is added to all new consultations unless a text is added from another source (for example, appointment reason set up).
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Allow finalizing consultations with draft clinical notes: When this setting is selected, consultations can be finalised with draft clinical notes.
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Enable unapproved clinical notes (Only available when student features are used): When this setting is selected, users with appropriate permissions can write unapproved clinical notes, and the notes can be approved or rejected by the consultation supervising user. Unapproved clinical notes are typically used in university clinic workflows where, for example, students, assistants, and interns can write clinical notes which must be approved and further processed by a supervising veterinarian. Only approved notes are shown in the patient history.
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Enable clinic location specific clinical note template types: When this setting is selected, the template selection dialogue on the consultation page only shows those clinical note types in the note type filter list for which the active clinic location has templates. For example, if Clinic A has templates for clinical note types 'Anamnesis', 'Triage', and 'Clinical examination' and Clinic B only has templates for 'Anamnesis' and 'Clinical examination', a user on Clinic B only sees clinical note types 'Anamnesis' and 'Clinical examination' in the note type list. If this setting is not selected, the user also sees clinical note type 'Triage' even though no templates are available for it.
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Allow editing text entries of finalized consultations: When this setting is selected, clinical notes can be added and edited on finalised consultations. When the setting is not selected, adding and editing clinical notes on finalised consultations is possible, but the system requires a reason when a user adds or edits a note.
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Consultation text entry editing limit: When the previous setting is selected, you can define the number of days clinical notes can be edited on finalised consultations.
The task-related settings below depend on the clinic location setting Allow finalizing consultations with draft clinical notes being enabled. You may also need to enable Multiple clinical notes for outpatients and home calls.
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Create tasks of draft notes upon invoice finalization: When this setting is selected, a task is created automatically when an invoice is finalised for a consultation which includes draft clinical notes.
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Default assigned user for tasks about draft clinical notes: In this field, you can select the user who the task is assigned to: created user (the user who created the draft notes), active user (the user who finalised the invoice), or supervising veterinarian (the veterinarian responsible for the consultation).
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Deadline (in days) for draft note tasks: In this field, you can define how many days after invoice finalisation the task is due. Note that if you set the deadline as 0, a task is created with an immediate deadline when a draft clinical note is saved (not when the invoice is finalised).
These settings control the availability of clinical note functionality for user permission groups:
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Add clinical notes on consultation: Allows the user to create notes.
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Edit notes, discharge instructions and clinical notes made by other users: Allows the user to modify notes created by others. This is relevant for workflows where staff edit notes on behalf of a responsible professional.
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Add / edit discharge instructions and clinical notes after consultation has been finalised: Allows editing after the consultation is closed.
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Add unapproved clinical notes on consultation: Allows the creation of notes that require approval.
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Clinical notes made by students: Specific permissions for student workflows.
Clinical note types can be used to categorise clinical notes. On consultations and in patient history, clinical notes can be filtered and sorted by type. This can be useful when there is input from several employees and the clinical cases are more complex. By default, all notes are of the 'General' type. Clinical note types are available on consultations when the multiple notes workflow is used.
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Go to Settings > Lists & Templates > Lists.
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Select Add list button.
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From the Type drop-down list, select Consultation note type.
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In the Name field, type a name for the list.
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Select Save. The empty list is added to the Lists & Templates > Lists page.
To edit the list properties (type or name of the list) after saving, select the pen button on the list row.
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Select the list name (shown as a link) to open the list page.
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Select Add item. The Create list item dialogue opens.
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In the Code field, you can add an optional code for the clinical note type. The code is for internal use and can be any identifier you want to use. If codes are used, they must be unique within the list.
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In the Label field, type the clinical note type name.
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In the Clinic locations field, select the clinic locations you want the clinical note type to be available for. By default, the clinical note type is available for all clinic locations.
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Select Save.
To edit the code or label of a clinical note type after saving, select the pen button on the row. Note that you cannot edit a clinical note type if it has been used for clinical notes.
With clinical note templates, you can make adding clinical notes easier and faster for users. In the appointment reasons, you can also select a clinical note template that is automatically added to the consultation when the reason is used.
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Go to Settings > Lists & Templates > Templates.
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Under Text templates, select Add.
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From the Type drop-down list, select Clinical note template.
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From the Note type drop-down list, select the clinical note type you want this template to be available for. If you select nothing, the template is available for all clinical note types.
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Add a Title for the template and add the template text.
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From the User drop-down list, you can select a specific user who can edit the template (other users can only use it). If you do not select a user, only users with the rights to add and edit templates through the settings can edit the template.
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In the Clinic locations field, select the clinic locations you want the template to be available for. By default, the template is available for all clinic locations.
To edit a template after saving, select the pen button on the row. For more information about creating text templates, see Create and manage text templates.
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