- Progress Notes can be created or viewed from the Clinical Module by selecting Clinical on the sidebar of the Client Record or by right-clicking on the List or Calendar View
Creating a Progress Note
Appointment Today
- On generating Progress Notes, they must be associated with an appointment/encounter
- If there is an appointment today, select Appointment today. Begin Progress Notes
- Should there be existing Progress Notes for today, you are prompted to Continue with that Progress Note
- On responding No, you are prompted to create a new Progress Note
No appointment today
- Should there be no Appointment for Today, you are prompted to create one (an Encounter). Could be a phone call or any other form of contact
- Progress Notes automatically populate with
- Date and Time
- Team Member/Provider
- System User
- They also populate with detail as you select the various options
- Past Notes can be viewed and additional notes appended
- Templates can be setup in Manage Auto Text to be selected
- The sidebar consists of
- Support for access to Support Online
- Audit
- MIMS Version
- Access to Alerts and Notes that are recorded in the Client Record in the General section. You can View or Add
- Access to the Patient's Admissions if you are a hospital. You can edit or create a new Admission
- Re: to generate
- a Referral
- Request for Imaging
- Request for Pathology
- Open any other Template
- Reason for Encounter with SNOMED AMT
- Observation
- Prescription
- Print to print Current Notes or All Notes
- Invoice to raise an invoice at the end of the Consultation
- Save and Close
Observations
Prescriptions
Electronic prescribing for prescribers (digitalhealth.gov.au)
- Select Prescription on the sidebar
- This launches the script pad and alongside on the left is the Medication form to select Custom Medications, Favourites, Favourite Sets and MIMS with MIMS being the default as long as the Provider has a subscription and has setup detail in Provider Setup – Direct CONTROL Medical (DCM)
MIMS
- Medications can be searched by Active Ingredient or Drug Name
About active ingredient prescribing | Australian Government Department of Health and Aged Care
- Commence typing the Active Ingredient or Drug Name
- Select PBS on the sidebar to access PBS online
- Select Product Info on the sidebar to view and print Product Information
- On selecting the Medication, Dose and Form populates
- Select Frequency (mandatory)
- Select Food and/or Region (Optional)
- Select Emergency Supply to generate
- With ePrescriptions, only one medication can be transmitted at a time. DCM will allow you to prescribe multiple Prescriptions by selecting Add on the sidebar of the Medication form. On transmitting, they will be sent individually to eRx
- Select Close and Save
- Select Print to print to PrePrinted Stationery. You will have the option of transmitting to eRx
- Select eRx to transmit the ePrescription
-
- Select Email or SMS to send the QRCode to the patient
- Select Print Paper Token to print and hand to the patient
- This is a printed prescription that has been transmitted to eRx
- Details of the Prescription are automatically saved to the Progress Note
- They are also saved in the Medication/Vaccinations section
View Past Notes
- Past Progress Notes can be viewed when working on a Progress Note by selecting View Past Notes to the right, or
- If not in a current Progress Note, Past Notes can be listed and viewed by selecting View Past Notes
Edit Progress Notes
Health records should not be altered. Once notes have been made, they should not be edited, erased or obliterated. Amendments in the normal course of patient management such as corrections, retrospective notes, entries made out of date or time sequence and addenda should record date and time of the alteration and by whom.
As requested by some based on their clinical needs, in Utilities - Configuration - Clinical there are the options to
- Allow edit within the next 24 hours
- Allow edit within the next 3 days
Append Notes
- Additional notes can be appended to Past Notes by selecting Append on the sidebar when viewing a Past Note