MellowoodMedical Online Help
PN - Progress notes tab
- Mhairi West
Creating a new progress note using a pre-loaded template
Select the Medical records/Progress Notes folder in the patient file
Ensure the Progress Notes tab is selected
Click the New button in the IDEAS toolbar to add a new note to the file.
A window will appear with a list of templates available.
You can view all available templates by selecting "Show All Options" (default) or select a category from the left hand side to view those listed under a specific category.
Double click on the required template name or click once to select and click “Save”.
For information on creating progress note templates follow this link IDS6150 Paragraph templates
The Progress Note will open in a separate window.
The window that the Progress Note template appears in remains the same regardless of the template selected.
Enter details in the upper portion - ideally all of these fields should be completed.
Some will auto-populate such as the “Date”, “Time”, “Treatment cycle” and “Staff member”.
The “Duration” and “Subject” must be completed by the user.
Answer the questions in the progress note
Remarks box;
Free text comments can be added to the remarks box at the bottom of the window. You can also have some answers appear in the Remarks box as well as in the questions section
If you have a comment that will be regularly added to the remarks box, you may wish to make use of paragraph templates, which will save you typing in the whole comment each time.
Press Save and Close.
This progress note now appears in the notes entered for the patient.
Signing off progress notes
We recommend using the sign off function when completing Progress Notes. These notes should be considered the equivalent of written records in a patient chart, and should be signed off electronically in the same way that written records would be signed, to prevent unauthorised editing, and allow traceability in record keeping.
For more information click here Signing off records
Viewing existing progress notes in the patient file
Click the "Progress Notes" tab in the Medical Record folder to view existing Progress Notes that have been saved to the patient file.
There is a drop down box titled "Filter on:" that allows you to view only notes associated with a specific category.
These options match the categories assigned to the Progress Note Templates in System Configuration allowing the user to only view those records in a specific category.
Double click on the note to open it.
The Progress Note will open in a separate window. It will display the list of questions in that template, and any completed answers.
For detailed information about this window click this links;
Filtering Progress Notes
In the “Progress Notes” tab there is a drop down box titled “Filter on:”
Use the down arrow to reveal the available options. These options match the categories assigned to the Progress Note Templates allowing the user to only view those records in a specific category.
This can be filled in the category of the Progress Note template.
