Patient Electronic Health Records

Elements and format of a patient's health record

Your patients' electronic health records form a part of their patient profile and ensure you can securely access patient records across your practice locations and in your home, irrespective of which computer system you use and without the need to maintain two HealthKit accounts for the one practitioner. You can also review a patient's clinical and health history, so you can ensure you provide treatment that is optimal to their needs.

Electronic health records encompass case notes, reports, referrals, clinical overview, social history and other clinical records. They also enable you to add images, and upload and attach files to case notes.

Clinical templates

Main articles: Preset clinical templates and creating your own templates, Selecting templates and Creating clinical overview templates

Clinical templates for case notes, letters and clinical reports are either preset for you from HealthKit's template library based on your profession and the fee or referral that you select when making an appointment, or you can create case note, letter and clinical report templates yourself. You can create templates, add attachments or link templates to fees and reports in the template section of your Settings page.

Accessing and viewing a patient's health record

Access clinical notes from - 1: your calendar and 2: a patient profile

Main articles: Elements of a patient health record, Patient's social history

A patient's health record includes their case notes, appointments, referrals, reports, assessments, social history, general notes and any other records associated with a patient's health. A patient's Clinical tab is structured so that you can see each element of their clinical record down the left-hand side in blue, with the current record that you are viewing in green, and attached files in grey.

You can access a patient's clinical record in two ways:

  1. From a patient's profile: go to the patient's profile from your Patients List, invoice or your calendar, then click the Clinical tab; and
  2. From your Calendar: When an appointment has been made with the patient on your calendar, click the appointment on the calendar, and click the Notes button.

Practitioners with the appropriate level of access can also click the Social History tab on a patient's profile to view and edit their demographic background and details.

Creating clinical notes, reports and letters

You can create and begin a patient's clinical note in two ways:

  • From your calendar: click on an appointment that has already been made, and click the Notes button to go to the clinical notes specific to that appointment; and
  • On their patient profile: click the Clinical page, then click the New clinical note button. This method is best used when there is no appointment associated with the clinical note. You can choose the type of record that you are creating.

You can then begin entering notes into the clinical note that you have created.

Searching for records

Searching for a particular health record

You can use the search filter at the top left hand side of the page to search for particular clinical records. You can also choose to display these records in reverse order or chronological order. Click the Save button to retain the setting for future use.

Clinical tools, tests and assessments

How to access HealthKit tools, tests and assessments
How to select HealthKit tools, tests and assessments

HealthKit includes a broad range of clinical tools, tests and assessments, including:

  • Mental health: such as K10, DASS21 and DASS42;
  • Physical therapy and disability: such as the Orebro Musculoskeletal Pain Questionnaire, and the WHODAS 2.0 (WHO Disability Assessment Schedule 2.0);
  • Medication management: including prescriptions; and
  • General tools: including the AUDIT alcohol screening tool;

as well as many other tools, tests and assessments that can be completed during appointments or shared with patients. All tools include the ability to input relevant patient information, as well as scoring where required.

You can access clinical tools by clicking the Templates button in the formatting bar, and then either:

  1. Selecting the tool from the list (which you can scroll through); or
  2. Typing the name of the tool in the search field and selecting the tool from the list.

After you click on the tool, the tool appears on the right of the screen. Click Save to add it to this clinical note. You can then complete the tool, or, if available and appropriate, share the tool with the patient.

You can develop your own clinical tools, and you can also link clinical tools, tests and assessments to fees and referrals, so that the clinical tool automatically appears for appointments covered by the fee or the referral.

Timestamp and adding questions

You can also add extra questions to the clinical tool by clicking the Plus icon on the right-hand side of the screen and selecting the question from your existing list or HealthKit's preset questions if it is listed; or if the question is not listed, adding the question and answering now.

Note: It's important when you add a new template (or clinical tool) to avoid overwriting any existing general appointment notes. For more information on creating clinical notes watch this video.

Monitoring and tracking your patient's health during an appointment

Any clinical tool that has a question with a measurement, such as weight, can be timestamped. For example, you can measure the patient's blood pressure when they arrive and 30 minutes later. To do this, add the tool again under the appointment and click the timestamp.

Annotatable body charts

You can track treatment, patient pain and body assessments on annotatable body charts, which you can see in this video.

To access a body chart, click the Templates button and select the relevant body chart. When you click Save, the body chart is shown in your clinical notes. You can annotate the body chart in two ways:

  1. Drawing: draw on the chart with your mouse (this is the default option); or
  2. Text: which can use in the following way:
    1. Click the Text button,
    2. Drag the text box that appears to the relevant area of the body chart;
    3. Click in the text box;
    4. Type the words; and
    5. Click Save.

Your annotations appear on the body chart.

Click the New clinical note button to add detailed case notes about the body chart.

You can also share the body chart with your patients, and link the body chart to fees and referrals if the body chart is always required for a specific fee or referral.

Note: If using a template and clinical note together, it's important that you select your template first as adding a template will overwrite any notes that are entered.

Creating Orders

Creating new clinical orders

HealthKit gives you the ability to write prescriptions and orders for patients, including pathology and clinical imaging to help you investigate and manage your patient’s pain, and treat their conditions.

To create an order, click the Add Order button and select the relevant order type. For prescriptions, select Create. For other orders, select the type and start entering the Laboratory. If the Lab is new, click to add the lab as a new organisation and complete the details for the lab. Click Submit to save and create the order.

The order now appears as a branch in the tree under the date. Click the Add Test button, enter the name of the test and any other information you require. Either click Save or if you need to create more orders (of the same type, i.e. imaging or prescriptions etc.) click Save & add another.

Publishing your orders and adding results

The order must be published before it can be printed. Click the triangle on the right hand side of the page and select Publish. Confirm that you want the order to be published and you can now print it.

When the results are returned, you can update the results by clicking the Edit icon and selecting a status. You can also add the results by clicking the Add Observation link and completing the details. Then click Save or Save & add another.

You can also attach any results that have been returned by clicking the Attach a File button.

For prescriptions, when the order is created, click the Add Drug button and choose if the drug is PBS or Private. Complete the required information including:

  • Drug;
  • Dose;
  • Repeats; and
  • Dispense Qty.

All other information is optional. You can click on the PBS, Product info or CMI buttons for more information about the drug. Click Save or if you are writing more prescriptions, click Save & add another.

Formatting patient records

Formatting patient records

Main article: Formatting patient records

Once you have created the required patient record (or once it has automatically been created for you), you can begin entering patient records, including case notes, letters, referrals, reports and assessments. Formatting your records is similar to formatting in Microsoft Word, and you can format text and paragraphs, move text, add tables and lines. You can also add images and dynamic terms, as well as select your preferred template. You can also change the size of your screen to maximise the editing space available.

Updating fees and invoices from patient records

Adding fees when writing patient records

You can add fees and edit invoice fee amounts while writing patient records. First click the down arrow next to the invoice number, then:

  • Changing the fee amount or details for this appointment: click the Edit icon next to the fee, and make the changes required;
  • Adding another fee to the invoice for this appointment: click the Add Fee button, then select the fee that you want to add to the invoice (or add the fee to your Fee List here if it is a new fee) and click Save.
  • Deleting a fee: click the Delete icon next to the fee and confirm that you want to delete the fee.

Click the up arrow next to the invoice number to collapse the view.

Saving and publishing patient records

Saving, publishing and deleting patient records

All patient records including case notes, reports and letters are automatically saved as you type. You can also click the Save button at the top right. Once saved, the status of a patient record is recorded as Draft. If your internet goes down or becomes very slow, you receive a notification telling you to manually save the note by clicking the Save button because otherwise automatic saving may be affected.

Medical professional codes of ethics require practitioners to lock down their patient records once you have confirmed and finalised it. Publishing (i.e. locking down) a patient record makes it load faster because the text editor does not need to be loaded. You can publish (i.e. lock down) a patient record by clicking the small arrow to the right of the Save button and selecting Publish. Publishing converts dynamic text to the actual words - for example, [Patient given name] [Patient surname] becomes the patient's actual name (e.g. John Smith) when it is printed. You can see more in this video.

You have limited rights to revert a published patient record to Draft status. Click the Revert button (or the small arrow to the right of the Revert button) that appears at the top right of published patient record, and confirm that you want to revert the note to Draft status. Once reverted, you are able to make changes to the record. Watch this video for more information.

Sharing a patient record and assigning tools

Sharing patient records

Where you deem it clinically appropriate, you can share a clinical note with:

  • Another practitioner in your group whose access level would otherwise not let them access the clinical note (e.g. if the practitioner has Personal Access and so can only see their own direct patients' records and not other practitioners' patients' records), which is particularly helpful when the practitioner must treat the patient unexpectedly; or
  • The patient themselves.

To share the clinical note, click the small arrow to the right of the Save or Revert button (if the note is in draft status, sharing the note converts the note to published status), and select whether you want to share it with the patient or another practitioner in your group. If you select that you want to share the clinical note with another practitioner in your group, select the practitioner's name from the Practitioner drop down menu. You can also select that you want to share not just this clinical note but the entire patient file with the practitioner.

After you click Save, the record is made available in either the other practitioner's HealthKit in their Patients List and the patient's profile, or in the patient's HealthKit patient portal.

When you have created a tool in HealthKit, you can assign the tool to a patient by clicking the Assign option under the Save button. The tool is assigned to the patient in their HealthKit patient portal for them to complete. When they have completed and saved the tool, it is shown in your list of clinical notes for that patient.

You can turn on or off the ability to share patient records and assign tools with patients on your Settings page (this feature is turned on by default).

Sending patient records securely

Sending messages securely to other practitioners

Patient records can be sent to other practitioners if both you and the receiving practitioner have an account set up with either ReferralNet or Argus. If you have not set up an account yet, you can do this from your Settings page. In order to send notes through secure messaging, you first need to have an account set up with either Referralnet or Argus.

To send a message to another practitioner, click the triangle next to the Save button and click either SMD ReferralNet or SMD Argus.

You can use any of the search criteria to narrow down the search. Search for the practitioner to whom you are sending the note. This will look through the ReferralNet or Argus database. Click Search. Select the Recipient and click Next.

A summary appears on screen confirming the details being sent. Select the message type and click Send when ready.

When a message is received via Secure Messaging, a notification is generated on your Dashboard. You can click on the View link to read the message.

A list of all messages sent and received are displayed in the Communications page, which is found under the Contacts tab.

Purchasing Healthkit credits

Patient records sent through secure messaging are 3 HealthKit credits per message sent. One credit is $0.22AUD.

If you need to purchase more credits, click the Buy Credits link. Enter the value of HealthKit credits that you would like to purchase and HealthKit tells you the number of credits that can be purchased for that credit amount (for example, $30 gets you 137 credits). Complete your payment details, and click the Add button to confirm purchase.

You can also buy and top up HealthKit credits in bulk and save, whilst improving your practice. You can read about bulk discounts on your Payments page.

Automatic top up of HealthKit credits

You can set HealthKit credits to automatically top up when there are 10 credits left, thus ensuring that you always have enough credits for messages to be sent without you needing to check how many credits you have left.

Auto topup is initially disabled. Click the Edit icon and select Enabled. Enter the value of HealthKit credits that you would like to purchase and click the Submit button to confirm purchase.

Watch this mini video for more information on HealthKit credits.

Deleting a patient record

To delete a part of a patient's record (e.g. a case note, clinical report or letter), click the small arrow to the right of the Save button when a record is in Draft status. Select Delete from the drop-down menu and confirm that you want to delete the record. The record is then removed from the health record listings down the left hand side.

You can only delete patient records that you own, and you cannot delete a patient record if it has been published for longer than two weeks.

You can also delete a full patient profile on their General page; click here for more information.

Printing patient records

Printing patient records
Clinical note contents and template printing preferences

You can print either a single patient case note or all the patient's case notes. There are two ways to print clinical records:

  1. By clicking the print and print preview buttons at the top right of the screen, which prints a patient note using your connected printer on your letterhead; and
  2. By clicking the triangle next to the Save button and selecting print - this is also how you print all of the patient's case notes.

When printing, you can:

  1. Preview what records look like printed;
  2. Print records; and
  3. Set your preferences for the format of printed records.

Click the Preferences icon to set your content and template preferences for printing clinical notes. You can choose to print (a) just the contents of the clinical note; (b) the contents and appointment details or (c) the contents, appointment details and invoice details. You can also choose whether to include your header and footer on the note or not, or whether to include your header and footer on the first page only.

When you print a patient record, dynamic terms are automatically converted to actual words - e.g. [Patient given name] [Patient surname] becomes the patient's actual name (e.g. John Smith) when it is printed.

Watch this video to see how to do this.

Videos

Why aren't my notes there when I look for them ?

Always Publish your notes when you are finished with them. This will ensure they are not overwritten.

How do I use annotatable body charts?

Click the templates button on your clinical note to access annotatable body charts.

How do I print clinical notes?

On the clinical note, click the triangle next to the Save button and select Print; you can then select whether you want to print only this note or all of the patient's clinical record (you can also determine the format for the printed clinical notes).

How do I link referrals to existing clinical notes?

If the clinical note or letter isn't linked to your referral, from the clinical note, click the Edit icon next to the note title and select the relevant referral. When you save, the referral details are automatically populated for you when you Print or preview the note.

How do I send patient notes through secure messaging?

You need to ensure both you and the receiving practitioner are both registered with the same SMD service and the service is enabled under your Settings. From the patient's Clinical page, click the black triangle and select the delivery service. Complete the search, select the information to send and click Send.

My practitioners have Personal Access - how do I share specific patient records between practitioners?

On the General page of the patient's profile, click the Edit icon under Practitioner Relationships and add the practitioner to the patient's practitioner relationships and determine the relevant access level.

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.

How do I create a new clinical note? And how do I link a referral to it?

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.