Patient Notes: Difference between revisions

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= Patient Notes =


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The '''Patient Notes''' section of the VEHRDICT system enables clinicians to document observations, treatment plans, and relevant visit details. These notes support continuity of care and provide a written record that helps track patient progress over time.
        <h1>Patient Notes</h1>
        <p>In the <span class="highlight">Patient Notes</span> section of the VEHRDICT system, clinicians can document observations, treatment plans, and any other relevant details regarding patient visits. Always ensure to provide clear and succinct notes to support continuity of care.</p>
       
        <p>For instance, under <span class="highlight">Patient Notes List</span>, you might see entries like <span class="highlight">2023-11-06: SUBJECTIVE: The patient presented with updated symptoms during today's evaluation.</span> This aids in tracking patient progress and communicating with other healthcare professionals.</p>
       
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            <h2>Step 1: Access Patient Notes</h2>
            <p>Navigate to the <span class="highlight">Patient Dashboard</span>, and then click on <span class="highlight">More...</span> and select <span class="highlight">Patient Notes</span> from the dropdown menu.</p>
           
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        [[File:PatientNotes.jpg|800px]]
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            <h2>Step 2: View and Add Notes</h2>
            <p>From the <span class="highlight">Patient Notes List</span>, you can view existing notes or click <span class="highlight">Add New</span> to document new observations and treatment plans.</p>
           
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In the "Patient Notes" section of the VEHRDICT system, clinicians can document observations, treatment plans, and any other relevant details regarding patient visits. Always ensure to provide clear and succinct notes to support continuity of care. For instance, under "Patient Notes List," you might see entries like "2023-11-06: SUBJECTIVE: The patient presented with updated symptoms during today's evaluation." This aids in tracking patient progress and communicating with other healthcare professionals.
For example, entries may look like:


> '''2023-11-06: SUBJECTIVE:''' The patient presented with updated symptoms during today’s evaluation.


[[File:PatientNotes.jpg|800px]]
This allows providers to reference previous encounters easily and collaborate effectively with other care team members.
 
[[File:patient_notes_nx.jpg|center|800px|Patient Notes List]]
 
== Accessing Patient Notes ==
 
To access and add notes for a patient, follow these steps:
 
# Navigate to the '''Patient Dashboard''' and select the appropriate patient.
# In the left sidebar, click the '''Patient''' dropdown and select '''Patient Notes'''.
# Click '''Add New''' to create a new entry.
# This will open the note editor, where you can:
## Insert free text notes
## Process the content with VEHRDICT AI
## Apply reusable templates
## Export the note
 
[[File:patient_notes_edit_nx.jpg|center|800px|Patient Notes Editor]]
 
{{Tip|Use the AI button to auto-generate a SOAP (Subjective, Objective, Assessment, Plan) template based on recent vitals or encounter notes.}}
 
== Best Practices ==
 
* Keep entries clear, concise, and clinically relevant.
* Use consistent headings such as '''Subjective''', '''Objective''', '''Assessment''', and '''Plan''' (SOAP format).
* Reference key changes since the last visit to improve continuity of care.
* Leverage templates for common visit types (e.g., annual physicals, post-op follow-ups).
 
{{Warning|Avoid including sensitive non-medical commentary. Notes should remain professional and patient-centered.}}
 
== Summary ==
 
The '''Patient Notes''' tool is integral for clinical documentation in VEHRDICT, enhancing collaboration, reducing redundancy, and ensuring accurate, real-time insights across the care team.

Latest revision as of 16:18, 20 June 2025

Patient Notes

The Patient Notes section of the VEHRDICT system enables clinicians to document observations, treatment plans, and relevant visit details. These notes support continuity of care and provide a written record that helps track patient progress over time.

For example, entries may look like:

> 2023-11-06: SUBJECTIVE: The patient presented with updated symptoms during today’s evaluation.

This allows providers to reference previous encounters easily and collaborate effectively with other care team members.

Patient Notes List
Patient Notes List

Accessing Patient Notes

To access and add notes for a patient, follow these steps:

  1. Navigate to the Patient Dashboard and select the appropriate patient.
  2. In the left sidebar, click the Patient dropdown and select Patient Notes.
  3. Click Add New to create a new entry.
  4. This will open the note editor, where you can:
    1. Insert free text notes
    2. Process the content with VEHRDICT AI
    3. Apply reusable templates
    4. Export the note
Patient Notes Editor
Patient Notes Editor

Tip: Use the AI button to auto-generate a SOAP (Subjective, Objective, Assessment, Plan) template based on recent vitals or encounter notes.


Best Practices

  • Keep entries clear, concise, and clinically relevant.
  • Use consistent headings such as Subjective, Objective, Assessment, and Plan (SOAP format).
  • Reference key changes since the last visit to improve continuity of care.
  • Leverage templates for common visit types (e.g., annual physicals, post-op follow-ups).

Warning: Avoid including sensitive non-medical commentary. Notes should remain professional and patient-centered.


Summary

The Patient Notes tool is integral for clinical documentation in VEHRDICT, enhancing collaboration, reducing redundancy, and ensuring accurate, real-time insights across the care team.

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