Completing and formatting patient records
You can begin typing a case note or clinical report in the main part of the patient's clinical record, and you can also select or change the template from your own or HealthKit's template library. When you are typing your notes you can change the formatting of your text in numerous ways that are very similar to Microsoft Word.
- 1 Selecting templates
- 2 Changing the title of a note
- 3 Adding files and images
- 4 Adding your signature
- 5 Using dynamic terms
- 6 Maximising the view
- 7 Moving text
- 8 Formatting text
- 9 Formatting paragraphs
- 10 Adding tables and lines
- 11 Videos
The template for a clinical note is blank, unless the appointment has a pre-set template assigned to it. You can change the template for the clinical note by clicking the Templates button and then selecting the template that you want to use from either your current templates or HealthKit's template library or you can add a new template. Selecting and saving the template replaces existing words within a note unless you choose not to replace the existing content. Click the Save button to confirm the new template to be used for this clinical note.
Changing the title of a note
The title of a note is set by default - e.g. the title is Appointment if the clinical note is for an appointment; the title is Clinical Note if the clinical note was created by you clicking the Clinical Note. Click the Edit icon next to the title to change the title to something else that you think is more appropriate. You can also change the date of the note, and link it to an appointment or referral if appropriate.
Adding files and images
You can upload files (such as photos, scanned handwritten case notes, referrals etc) of up to 5MB to patient records. Click the Add File button, then browse to find the correct file and click Upload. Note that these field names are dependent on which browser you are using (e.g. Chrome, Firefox, Safari, Internet Explorer, etc), however the process is the same regardless of which browser you use.
Adding your signature
You can add your electronic signature by clicking the Add a logo or other image button on the toolbar. Click the Add File button, then browse to find the correct file and click Upload. Note that these field names are dependent on which browser you are using (e.g. Chrome, Firefox, Safari, Internet Explorer, etc), however the process is the same regardless of which browser you use. You can then use the template editing tools to move the signature around.
Using dynamic terms
You can use and select dynamic terms from the Dynamic Terms list to add terms such as patient's date of birth to a clinical report or note without you having to look it up and type it out yourself. Using dynamic terms is also very helpful when you are creating a clinical template that can be used regardless of who the patient is, without editing information each time. For example, you are writing a clinical note and want to insert the patient's date of birth but you do not know it off the top of your head; select Patient DOB from the Dynamic Terms dropdown menu and [Patient DOB] appears in your notes. When printed or published, the patient's date of birth appears. Watch this mini-video for more information about dynamic terms.
Maximising the view
You can enlarge the area in which you add your clinical notes by clicking the Maximize button in the formatting section. Clicking the Maximize button expands the view so that your notes area takes up the whole screen. You can toggle back to the normal view by clicking the same button (now called the Minimize button, and in dark grey) in the formatting section at the top of the screen.
You can move text within a clinical note, between clinical notes and between your HealthKit account and other programs outside of HealthKit. The moving text icons are located at the top left of the formatting section, and they function similarly to the same icons in Microsoft Word. The moving icons are:
- Cut: highlight text and click the Cut icon to remove it from the words on your screen, so that you can paste it elsewhere in your notes or in another program.
- Copy: highlight text and click the Copy icon to copy the text so that you can paste it elsewhere in your notes or in another program.
- Paste: click in the note where you want to paste the text and click the Paste icon to insert the text at this point.
- Paste as plain text: does the same as the Paste icon but inserts the text without any formatting from the text you copied. For example, if the text you copied was bold and you paste it as plain text, it is inserted as non-bold text.
- Paste from Word: does the same as the Paste icon but for text that you have copied from Microsoft Word.
- Undo: click to undo your last action.
- Redo: click to redo your last action.
You can format text within a clinical note using the text formatting icons in the top right of the formatting section of a clinical note. These icons function similarly to the same icons in Microsoft Word. The formatting text icons are:
- Bold: makes selected text bold: e.g. text.
- Italics: makes selected text appear in italics: e.g. text.
- Underline: underlines selected text: e.g. text.
- Strike through: strikes through selected text: e.g.
- Subscript: makes selected text appear as a subscript below the normal line of text: e.g. text.
- Superscript: makes selected text appear as a superscript above the normal line of text: e.g. text.
- Text color: makes selected text appear in the colour that you choose from the colour picker: e.g. text.
- Font type: makes selected text appear in as a pre-selected font style, such as heading or normal: e.g. text.
- Font selector: makes selected text appear in the font that you choose: e.g. text.
- Font size: makes selected text appear in the font size that you choose: e.g. text.
You can format paragraphs within a clinical note or report using the paragraph formatting icons in the bottom left of the formatting section of a clinical note. These icons function similarly to the same icons in Microsoft Word. The paragraph formatting icons are:
- Numbered list: list points in a numbered list.
- Dotpoint list: list points in a dot-pointed list.
- Decrease indent: decrease indentation of a list.
- Increase indent: increase indentation of a list.
- Quote: place selected text in an indented paragraph with quotations around it. This is particularly helpful for direct quotations from patients about their subjective state.
- Align left: align text in a paragraph to the left.
- Center: center text so that each line is anchored in the middle, with different widths for each line.
- Align right: align text in a paragraph to the right.
- Justify: align text so that each line is the same width.
Adding tables and lines
You can add a table within your clinical note or report using the Table icon. You can then select the number of columns and rows, and also add headings and determine border thickness to format the table. You can also add a horizontal line to create separate sections in your clinical note by clicking the Line icon.
How do I add or scan files to a patient record?
On the clinical note, click the Add File button. You can now locate the file and attach it to your note.
On the clinical note, click the New clinical note button, then click the Template button. Choose the type of template you require, make your notes then click the Edit icon next to the note title and select the relevant referral.
How do I use dynamic terms
Use dynamic terms to help you write clinical notes and reports.