Medical Notes Window
Medical information about a client's condition is created and maintained via the Medical Notes window following an appointment with a clinician.
Use the Daily Notes toolbar on the Medical Notes window to view or edit medical information about the current condition.
Click on a label to view or edit notes about the current client condition:
- Initial Notes: the medical
notes collected during the first appointment/assessment and represent
the baseline.
This label is only available once notes have been created for a follow-up appointment.
- Subjective: the subjective
medical notes collected for the current appointment (aka follow-up
appointment).
- Objective Type: the objective
medical notes specific to the injury for the current appointment.
The default Objective Type can be defined in the clinician's medical notes settings.
To change the objective type or include additional ones in the current notes, use the Injury #N drop-down list.
- Treatment/Analysis/Plan:
defines treatment details and the patient goals for the condition.
IMPORTANT!
Patient Goals and ALL red labelled fields will NOT be copied over as these are linked to a specific Condition.
BEFORE changing the Condition on the Appointment, PLEASE take a copy* of the original Medical Notes Window, including the Outcome Measures window.
Once you have changed the Condition on the Appointment, edit the Medical Notes and Outcome Measures Windows and enter in the details again.
(* Use a text editor or take a screenshot to copy and save the notes locally)