What's New in Version 14.0 > Charting Features
Clinical notes have received enhancements in the following areas:
You can now access clinical notes from several areas outside of the charting module.
A Clinical Notes option has been added to the List menu on the Main Menu bar, enabling you to display the Generic Clinical Notes window without opening a patient's chart. Select List > Clinical Notes > Generic Clinical Notes to display the Generic Clinical Notes window.
See List Menu Commands and Handling Generic Clinical Notes for more information.
A Generic Notes option has been added to the Options menu of the ADA List and ADA windows. Clicking this option displays the Generic Clinical Notes window, which contains a list of all generic and default clinical notes associated with a particular code, sorted by provider ID.
A Clinical Notes option has been added to the List menu on the Main Menu bar, enabling you to display the Work Performed window without opening a patient's chart. Select List > Clinical Notes > Post End of Day Notes to display the Work Performed window.
See List Menu Commands for more information.
In past versions of the software, you did not have the option of adding clinical notes at the end of the day and adding clinical notes while posting. (The Post End of Day Notes menu option was disabled if Add Clinical Notes While Posting was selected in the Chart Properties window.) Now, the Post End Of Day Notes menu option is always enabled, regardless of the setting in the Chart Properties window.
The Info tab of the Patient Clinical Notes window now contains a Procedure Date field next to the date and time the note was created. This enables you to post a clinical note on a date that is different from the date on which the procedure was performed.
When you add a clinical note in the Patient Clinical Notes window, the Procedure Date field defaults to today's date, and the Date Created area displays the date and time the note was created.
When you add an end-of-day clinical note, the Procedure Date field defaults to the date you selected in the Work Date field, and the Date Created area displays the date and time the note was created.
See Adding Clinical Notes at the End of the Day for more information.
You can now edit a saved clinical note, provided you are editing the note on the day it was created and you have the proper security permissions.
When you select a clinical note created today, an Edit Note Text button is displayed. When you click the button, the current note text from the Notes History tab is displayed in the note field on the Info tab, and the date stamp is removed. You can edit or add to the note, and the edited text replaces the current note text. When you click OK, the date stamp is added to the edited note text.
See Editing Patient Clinical Notes for more information.
Several changes have been made to the Clinical security permissions:
The Modify and Delete Clinical Notes security permission has been replaced by the Amend Clinical Notes (anytime) and the Delete Clinical Notes security permissions.
Users who were assigned the Modify and Delete Clinical Notes security permission in past versions are now assigned the Amend Clinical Notes (anytime) and Delete Clinical Notes permissions. These permissions are set to OFF for new users.
The override for the Delete Clinical Notes security permission is on the Clinical 2 tab of the System Settings-Override Settings window.
A new Clinical security permission, Edit Clinical Notes (until end of day), has been added.
By default, only the top-level user is assigned this security permission. This permission is set to OFF for all other existing users, as well as newly added users. The top-level user can assign this permission to other users, as necessary.
You no longer need to manually add a clinical note for procedures that do not actually require a note or for simple procedures that always require the same default note.
A Clinical Note drop-down list has been added to the Information tab of the ADA/Transaction Codes window. The list contains the following options:
Manually add a note—If you select this option, you are prompted to add a clinical note when you post the code. If you enter clinical notes at the end of the day, the code is displayed in the Work Performed window.
Automatically add the default note—If you select this option, you are not prompted to add a note after posting, and the code is not displayed in the Work Performed window. Instead, the default note (which you have previously assigned) is added automatically. If a default note has not been assigned, the software defaults to the process for manually adding a note.
Never add a note—If you select this option, you are not prompted to add a note after posting, and the code is not displayed in the Work Performed window.
See Adding ADA, CPT, and Transaction Codes for more information.
You can now add clinical notes at the end of a visit, instead of after each procedure.
A new option, Add Clinical Notes Per Visit, has been added to the Clinical Notes section on the Chart tab of the Chart Properties window.
See Setting Charting Options and Properties for more information.
If you select the Add Clinical Notes Per Visit and Add Clinical Notes While Posting options, the Add Clinical Notes window is not displayed after you post individual procedures. Instead, the Add Clinical Notes For Visit window is displayed when you close the chart.
If you select the Add Clinical Notes Per Visit and Add Clinical Notes At End of Day options, the Work Performed Per Visit window is displayed when you select Clinical Notes > Post End of Day Notes.
See Adding Clinical Notes Per Visit and Adding Clinical Notes Per Visit at the End of the Day for more information.
You can now add default and generic notes for all providers, rather than just a single provider. You can also copy the text of a note to be shared by several providers.
In past versions of the software, when you added a patient clinical note and clicked OK, the software displayed a prompt, asking if you wanted to create a generic clinical note. Now, a prompt asks you if you want to create a generic clinical note for just this provider or for all providers.
See Creating Generic Clinical Notes from Patient Clinical Notes for more information.
When you add a generic note and select the Use this text as the default for this ADA Code option, a prompt asks you if you want to make a default note for this doctor or for all doctors.
See Creating Default Clinical Notes from Patient Clinical Notes for more information.
You can now copy a generic or default clinical note for a single provider or multiple providers.
When you access the Generic Clinical Notes window from the List menu, the ADA/Transaction Codes window, or the chart, a list of all generic and default clinical notes is displayed. You can use the Copy Note button in this window to create a new default note (containing all of the same information that is on the currently selected note) for each provider you specify.
See Copying Generic and Default Clinical Notes for more information.
You can now copy all of the clinical notes of one provider to another provider.
A new menu option—Add Default Clinical Notes—is available from the Options menu of the Provider List and Provider windows. When you select a provider in the list and click Add Default Clinical Notes, the Add Notes from Selected Provider window is displayed, enabling you to select the provider from whom you want to copy notes.
See Copying Generic and Default Clinical Notes from One Provider to Another for more information.