Clinical note templates and smart phrases

Your own note templates

Owners and managers design the clinical notes under Forms & exercises → Note templates. Every clinic starts with editable starters: new patient assessment, routine skin and nails, nail surgery, verruca treatment, biomechanical / MSK assessment, diabetic foot check, vascular assessment and a SOAP note. Change them, copy them, or start a new one. The Written note stays built in, because Heidi and other scribes put their notes there; copy it if you want your own free-text note.

Fields

Each template has sections, and each section has fields: headings, short text and long text, choose one, yes or no, tick boxes, numbers with a unit (mm, °, mmHg) and a body site (which foot, then where on it). Choice, yes/no, tick and number fields can be filled in left and right separately. Mark a section as S, O, A or P to make a SOAP note, or press Add SOAP sections. Needed before signing stops a note being signed until it's filled in. Use Preview to see the note as a clinician will.

Default text and "Insert from last note"

A text field can start with default text, for example your usual advice. Tick Offer "Insert from last note" and the box gets a button that adds what that field said in the patient's last signed note, such as their medical history, so it doesn't have to be typed again. The note it came from is in the access log.

Smart phrases

At the bottom of Note templates, save the text your clinicians type often under a short code. In any note's text box, typing a full stop, the code and a space (`.nc `) puts the phrase in its place.

Which template a note starts on

On the template, tick the services it's the default note for: a note started from one of their appointments opens on it. A service has one default. Otherwise a visit uses the note chosen for its category (Settings → Categories), then the usual one for what the category works like. Under Who can use it, choose every clinician or only some; the others don't see it in the list. Clinicians can always pick another template when they press New note on the patient's record, in the order you set with the arrows.

Versions

Saving a change makes a new version. New notes use it from then on; a note already written keeps the version it was written on, so changing or archiving a template never changes a note, and an amendment stays on its note's version. Signing and locking work as before. Archiving takes a template out of the list; it can be brought back.

Calculations

The ABPI and diabetic foot risk suggestions look for fields by their reference (ankle and brachial pressures, monofilament, risk), which a copy keeps. Keep those fields in a copied vascular or diabetic foot template and the suggestions still appear.