[en] You can edit or remove text from clinical notes and discharge instructions even after a consultation has been finalized. This is controlled by user permissions and clinic settings, which may require you to provide a reason for the change. Depending on your clinic's location settings, there may also be a time limit for how long clinical notes can be edited without providing a reason.
[en] Required user permissions and settings
[en] Editing is possible if your user account has the required permission. Your clinic's settings will then determine the conditions under which you can perform the edit.
[en] You need the user permission: Add / edit discharge instructions and clinical notes after consultation has been finalized enabled. If you do not have this permission, please contact your clinic administrator.
[en] The system's behavior is controlled by the following settings, Settings > General > Clinic location > Clinic location settings:
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[en] Allow editing text entries of finalized consultations:
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[en] Selected (Enabled): Clinical notes and discharge instructions can be added and edited on finalised consultations. The system will not require a reason for the edit.
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[en] Not Selected (Disabled): 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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[en] Consultation text entry editing limit: When the previous setting is enabled, this defines the number of days clinical notes can be edited on finalised consultations without leaving a reason. If the time limit has passed, users with the correct permissions will still be able to change the text but will be required to add a reason.
Se tiver as permissões necessárias, pode ainda editar as notas clínicas e as instruções de alta depois de a consulta ter sido finalizada. No entanto, dependendo das definições, poderá ser-lhe pedido que indique um motivo para as editar. Poderá também haver um limite de tempo para a edição das notas clínicas sem indicação do motivo. O motivo é registado no registo de edição, que pode ser aberto a partir da ligação do carimbo de data/hora sob o campo da nota clínica ou das instruções de alta (com notas clínicas simples) ou na linha da nota clínica (com notas clínicas múltiplas).
[en] Edit or remove a clinical note or discharge instruction
[en] There is no specific delete option for a clinical note or a discharge instruction. To delete the content you must edit the note and remove the text.
[en] To edit or removeclinical note or discharge instruction text on a finalised consultation:
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[en] Go to the finalised consultation where you need to make the change.
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[en] Find the Clinical notes or Discharge instructions section.
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[en] To edit or remove text:
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[en] If you use multiple clinical notes, select the pen button at the end of the row for the text you would like to change.
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[en] If you use single clinical notes or for discharge instructions, you can edit the text directly in the text field.
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[en] Edit the text. If you want to delete the content completely, remove all text from the text field. The system will retain the clinical note title (if multiple clinical notes are used), but the content will be blank.
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[en] Depending on your settings, select Save, or the text will autosave.
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[en] Depending on your settings, you might be prompted to add a reason for the change.
Nota
[en] If you added clinical notes or discharge instructions to the wrong patient, copy the text before removing it. You can then paste the text into the right consultation, or add it as a note on the Communication tab for the correct patient.
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