Adding a clinical note

In this article we will demonstrate how to make a clinical note, and to make use used of all its features.

The first step is for you to log into your Healthware environment and click on all patients and then select the relevant patient that you want to make a clinical note for.

Upon accessing the patients file, you will proceed by clicking on Clinician Notes 

After clicking Clinician Notes, the below screen will appear and here you will select your relevant accordion. All these accordions are expandable fields that open up your notes. There are also accordions for notes from multidisciplinary team meetings and one accordion for private notes as well.

To record your note, click on the add note button on the right hand side of the screen 

After clicking on add note, the following screen will pop up. On this screen you will have the option to select between a clinical note and a general note. The clinical note has a subjective, objective, assessment, and plan layout, while the general note section has one field to type your notes in 

Clinical Note layout

General Note layout 

Once you have selected the relevant layout, you may then proceed to make your note via typing or making use of our speech to text feature by clicking on the blue mic you see next to the typing field.

Once you have made your notes and added any relevant attachments, you may then proceed to save by clicking the save button

After the note has been saved you will notice a user stamp, date stamp and time stamp.

You would also have the option of exporting your notes to PDF by clicking on the PDF sign in the left corner of the note