Adding Clinical Notes

---

Description

This quick guide demonstrates how to add, reference and edit clinical notes, prior to the checkout, and after the checkout.

About

It is very important that the visit clinical note is created within the charting module, attached to the correct date of service. The clinical notes can be referenced from the Charting module or from the Sidekick.

Contents

The following topics are covered in this quick guide:

1. Section 1 - Adding a Clinical Note Prior to Checkout
2. Section 2 - Referencing and Editing Clinical Notes
3. Section 3 - Adding a Clinical Note after Checkout

---

Steps

Section 1 - Adding a Clinical Note Prior to Checkout

1. If not yet in the Charting module, make sure the correct patient is at the top of the sidekick and click Charting

[Image of the sidekick with the Charting module highlighted]

2. Prior to checkout, the clinical note is attached to the Visit on the Treatment Plan Card.

[Image of the charting module with the name of a visit highlighted]

3. Locate the correct visit. It should say it is scheduled for the current date. Right click the Visit.

[Image of the Treatment plan card, highlighting this visit with a word bubble that says "make sure the visit says it is scheduled for the current date"]

4. The Visit menu opens. Click Add Note.

[Image of the visit right click drop down menu, with the option "add note" highlighted]

5. The Notes module opens where the note can be typed. Prior to checkout, the default Note Tag is  Treatment Planning.

[Image of the notes module with a clinical note and the tag "treatment planning"]

6. When the note is finished, click Save Note.

[Image of clinical note with the option save note highlighted]

7. The note is saved on the Treatment Plan Card just under the Visit name.

[Image of the tx plan card with the visit expanded and a note under the visit name]

---

Section 2 - Referencing and Editing Clinical Notes

1. The note added prior to checkout can be edited. Right click on the note to open the Notes menu to access additional options, including the option to Edit note.

[Image of a tx plan card with a note under an expanded visit with the note menu expanded]

2. Or click the Note to expand it on the Treatment Plan card.

[Image of a visit in a tx plan card with a note that has been expanded.]

3. After checkout, the Visit is moved to History. Click History to change the Charting module to History mode.

[Image of the left hand side of the charting module with the History option highlighted]

4. In History, locate the Visit by Date. It will say Invoiced in the Site column.

[Image of history with a checked out visit that has a note]

5. In the Notes column, there is a note icon to indicate a clinical note is attached to the procedures.

[Image of the history section of charting showing a visit with an associated note]

6. Click the Note Icon to access the clinical note for that date.

[Image of the note module opened from the history section of the charting module.]

7. Click the note to expand it for viewing, or right click the note to access the Notes menu.

[Image of the note module with a clinical note expanded and the right click note menu expanded]

8. Clinical notes are also accessible within the Sidekick. After the Visit is checked out, they can be found be sorting for Clinical History.

[Image of the sidekick with the notes module expanded and the tag filter filtering for Clinical History]

9. Click the note in the Sidekick to expand it, or right click the note to access the Notes menu.

[Image of the sidekick with the notes module expanded and filtered for clinical history. with the right click note menu open]

10. Clinical notes can be accessed in the Sidekick from any of the Curve Hero modules by sorting the Sidekick notes to display Clinical History notes.

[Image of the schedule with the notes module in the sidekick expanded with the filter list open]

---

Section 3 - Adding a Clinical Note After Checkout

1. If the clinical note is not added prior to checkout, it can be added after checkout in the History section of the Charting module.

[Image of charting in the History section, with the history button and a visit both highlighted]

2. If no note has been added prior to checkout, there will not be any note icon in the Notes Column of the History box.

[Image of the history section of charting showing a visit that does not have an associated not]

3. In the History box, right click on any of the procedures for the visit. This brings up the option to Add Note.

[Image of the history section of charting with the right click menu for a procedure open and the option to add note highlighted]

4. The Notes module opens. Enter the details of the note. the Note tag is set to Clinical History by default if the note is added after checkout. All clinical notes will be found under the Clinical History tag.

[image of the note module open with a new note, that has the tag clinical history]

5. Click Save Note when the note is finished.

[image of the note module open with a new note, that has the tag clinical history, and the option save note highlighted]

6. The clinical note added this way is attached to all the procedures for that date of service, and will sort with the procedures if the patients History is sorted.

[Image of the history section of charting sorted by procedure, showing a procedure that has an associated note]