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This is the heart of the patient’s record. As shown here, notes are kept in
three categories: clinical, phone, and medication. These categories help to
organize the patient notes and can greatly improve the charts. Clinical
notes are usually keyed by the therapist or can be dictated by use of some
popular voice recognition software programs.
As with the other screens,
the person using this screen can access scanned documents, the Patient
Information Screen, or generate a prescription. For doctors that choose to
enter their own information, this is handy, because all information is one
button away.
Referral letters can be generated with the touch of a button and even
emailed. This gives the practice a much more professional presentation to
referring Physician's.
Referral letters, with notes attached, are generated from here. Notes can be
faxed, emailed or printed. Transcriptionists or services use this screen, as
do therapists who like to type. Support staff uses it to enter phone call
information as well.
If you have voice dictation installed, the therapist can speak directly into
the screen and the computer will type the notes. Each therapist must ‘train’
the computer with their own voice, and if you are willing to do this, entry
can be quite fast. Make sure you have a relatively quiet area to dictate if
you elect this approach.
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