Description

Main screen where the provider performs the patient's clinical evaluation. It can be customized, according to the user's preference.

Access 

Through Clinical Records Todays Patients
  • Click on the Clinical button, in main menu. 
  • Select the patient from the Todays Patients section.
  • Once selected, click on the New Progress Note button, located at the top of the screen.
  • Or press twice on the patient. Patient should appear as unattended. (This section is for patients registered on the Appointments screen, as arrived at the office.)
Through Clinical Records Open Progress Notes
  • Click on the Clinical button, in main menu. 
  • Select the patient from the Open Progress Note section.
  • Once selected, click on the New Progress Note button, located at the top of the screen.
Through Clinical Records Search
  • Click on the Clinical button, in main menu. 
  • Select the patient from the Search section.
  • Once patient is selected, click on the New Progress Note button, located at the top of the screen. Or double-tap on the selected patient.
Through Past Encounters
  • Click on the Clinical button, in main menu. 
  • Select the patient from any section of the screen.
  • Then, click on the Past Encounters button, located at the top of the screen.
  • On the Past Encounters screen, click on the New Clinical Record button, located at the top of screen. 

Sections
  • Button: (Patient Information): Click on this button, to display the patient's demographic information. 
  • Link: (Insurances): Click this link, to access the patient's health plan information.
  • Last Encounter: Displays the date of the patient's last encounter.
  • Next Appointments: By clicking this link, the future appointments of the selected patient, will be displayed. The user will be able to create appointments from the same progress note, through the Go to Appointments link.
Buttons
  • Cancel: Cancels the progress note.
  • Settings: Allows to configure the Advanced Progress Note screen, according to user's needs and preference.
  • Edit: Allows to edit an open progress note. If the progress note is closed, the Addendum / Amendments screen, will be automatically displayed, as a closed progress note, cannot be altered.
  • Alerts: When pressed, displays the Clinical Decision Support screen, which apply to the patient. If this icon is red, it means the user has clinical alerts.
  • Leave Open: When pressed, allows to leave the progress note open.
  • Save: Allows to save the clinical evaluation performed on the patient, as part of the progress note.
  • Print: Allows to display the progress note, before being printed.
  • Previous: Allows to return to the previous screen.


  • Side Bar: This section, contains all the available item to perform the patient's clinical evaluation. These items can be configured and organized, according to the user's need and preference. It is configured in the Settings / Side Bar Settings screen.


  • Patient Dashboard: This section, shows the items concerning the patient's medical history. This section is configured in the Settings / List Sections Settings screen. Each area, provides functionalities that can be used during clinical evaluation. The available sections are:
    • Allergies: Active patient's allergies.
    • Evaluation Form History: Displays the patient's evaluation history. 
    • Evaluation Notes: List of evaluation notes by date and provider.
    • Immunizations: Patient's vaccinations.
    • IV: Serums administered to the patient.
    • Medication List: Patient's active medications.
    • Menstrual History: Displays the patient's last menstrual period.
    • Nurse Notes: Nurse's notes.
    • OB Summary: Summary of patient obstetrics.
    • Pending Orders: Pending laboratory orders.
    • Physical Therapy Notes: Notes on physical therapy.
    • Problem List: List of patient's diagnoses or active conditions.
    • Simple Vital Signs: Section where it displays the last recorded vital signs. Vital signs, can also be registered from this section.
    • Vital Signs: History of the patient's vital signs.
  • Clinical Evaluation: In this section, the patient's clinical evaluation notes are documented. There are three forms to be displayed:


  • Assessment & Plan: In this section, the narrative of the patient's clinical evaluation will be displayed, it will be according to the configuration made, using the Keywords. If there are no Keywords configured in the system, it will be displayed in white, so that the provider itself  writes the information. The user has three options, to select the format of the narrative of the clinical evaluation of the patient.


Option #1 Paragraph Style


Option #2 Sorted List Style


Option #3 When the None option is selected


  • Next Appointments (Link): Section where the future appointments of the selected patient are displayed.


  • Add Procedures Templates (link): Allows to add the Templates of procedures, to the clinical evaluation.
Tabs (Located on the right side of the screen)
  • [Smart Box] tab: Screen where the user can select phrases, medications, orders and frequent procedures.


  • [ Reminders tab ]: Section used as a tasks reminder.    


  • [ Notifications tab ]: Section displays all notifications.


  • Pestaña [ Closed Encounters ]: Displays all patient's closed encounters, where they can be viewed, downloaded and printed. It also has the option of Service History, where it shows the history of the codes of procedures and diagnosis used in closed encounters.


  • Service History: Shows the history of codes of procedures and diagnoses used in closed encounters.


  • Tab [ Summary ]: The patient's clinical summary will be displayed.

  • Pestaña [ Order Results ]: Allows to view the patient's lab order results.