Clinical Note Template



you hello my name is Ryan beard-off and in this video I'll show you how to use the chart to make a clinical note template we'll go to template setup now I'm just going to go to new template start a whole new one now I need to categorize my template where I will find it later so I'm going to choose clinical exam my templates purpose is to measure the blood pressure of the patient so let's start with blood pressure and then I want to begin my template with a line of text that will always be the same every time I use this so how about measured the patient's blood pressure now the next line I would like a prompt where the user can put in the systolic measurement of the blood pressure so I'll go to select setup and I'm going to glance through this list that to see if perhaps the prompt has already been created and is in use in another clinical note now it's not so I'll click new and I'll create a whole new one I call my blood pressure systolic and then I need a question that will appear on the screen so the user knows what they're responding to now what kind of an answer would I expect for that well probably a number so I'll pull my menu down and choose number amount and next it'll give me a default area now 120 is the standard normal measurement so I'll put that in there I'll highlight my prompt I'll click OK and that becomes part of my note I'll insert that into my text and then I can add some description to the end of that line this is again static text that will always appear this way I'm ready for another prompt the diastolic measurements so I'll go to new and we'll enter that prompt name I'm going to call it blood pressure diastolic and I'm alphabetizing it this way by putting blood pressure at the beginning so that in that menu they'll appear together and I need a question to appear on the screen very similar to what we did before here I will pick a number and then I'll pick the normal measurement would be 80 so we'll go with that the user will be able to change that later as you'll see I'll insert that into my text then I'll add a little bit of a description to the end and then for my final line I'd like to say where did they put the measure and cuff it was taken from where we'll be very scientific about our description here and then we'll go create a prompt like was it the arm the left arm the right arm the left ankle the right ankle so again creating a prompt a blood pressure measured where was the where on the body was it measured now this time I'm going to give the user a choice a response from a list so I'll leave this alone and choose one response from the list and I'll type my various possible answers here left arm right arm left ankle right ankle then maybe sometimes you just want to put it around their neck and squeeze hard no no we don't want to do that but anyway for a joke we'll put it in there we'll click OK we'll insert that into our text as well that will put a period at the end of the sentence and my my prompt is complete if I okay this and then I'll close out of here I can now find my prompt under clinical exams expand that category it's probably there at the bottom there it is double click on it and I'm ready to begin answering I could change those numbers or I can just leave them alone and there we go my note is created for more tips and tricks be sure to visit you

4 comments

  1. Gordon, the initial set up is "a lot of clicking and menu searching." Once it is set up, you can reuse that template by clicking it off of the menu for all of your patients, saving you a lot of repetitive typing day-after-day.

  2. thanks for the instructional video.
    Could you please paste more videos like this. I think its a wonderful way to learn.

  3. Good start, but I would really like to see a clinical dentist do an exam on a "complicated" patient and use the clinical notes to enter all the info. It seems like a lot of clicking and menu searching. Would just typing be faster? What does the malpractice lawyer and judge want?

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