Why Use This Function:

The Doctor Note is a structured clinical document used to record comprehensive consultation notes as part of a Patient’s medical record. It enables authorised members of the healthcare team to capture, review, and manage clinical information in a consistent and systematic format.

Clearly defined sections ensure that all key aspects of a clinical event are documented, while allowing each section to be completed, reviewed, and marked as complete individually.

It is especially valuable in a multidisciplinary care environment, as it supports clear communication and continuity of care between Practitioners, Nurses, Allied Health Professionals, and other members of a Patient’s healthcare team. By providing shared, standardised clinical records, it enables coordinated decision-making, reduces the risk of omissions or miscommunication, and supports safe, effective, and collaborative Patient care, ensuring that all clinical decisions, actions, and instructions are properly documented and traceable.

The Contents of This User Manual:

• History
• Examination
• Diagnosis
• Treatment
• Plan
• Nurse Instruction
• Quick Action Buttons

• This user manual will start on the Clinical screen, Doctor Note.

• For more information on navigating and using the Clinical screen, please refer to the user manual: Clinical Screen: Navigation and Use.
  

History 

A summary of the Patient’s past medical background and relevant health information.

• Click on the History panel.

• The History panel will expand.

?Please Note: This is a free text field, and notes must be typed out.

• Click on the text field to enter the History notes.

• Click on the Complete button to finalise the History notes.

?Please Note: This panel will automatically minimise upon Clicking the Complete button and will display a green Complete button.

Examination

The physical assessment performed by the Practitioner to evaluate the Patient’s condition.

• Click on the Examination panel.

• The Examination panel will expand.

• Click on the text field to enter the Examination notes.

Diagnosis

The medical conclusion identifying the condition causing the Patient’s symptoms.

• Click on the Diagnosis panel.

• The Diagnosis panel will expand.

• Click on the Diagnosis field to enter and search for the desired ICD-10 Code you would like to add. 

? Please Note: This field updates automatically as you type. You can search using either the diagnosis description or the ICD-10 Code. If you enter an ICD-10 Code, it will be automatically added once the code is fully typed.

• Select the desired ICD-10 Code.

? Please Note: You can add multiple ICD-10 Codes in the Diagnosis panel.

• Alternatively, Click on the Ellipsis button to use the ICD-10 Builder.

• The ICD-10 Builder will open.

• For more information on navigating and using the ICD10 Builder, please refer to the user manual: ICD10 Builder: Navigation and Use.

Treatment

The medical care provided to manage or resolve the condition.

• Click on the Treatment panel.

• The Treatment panel will expand.

• Click on the text field to enter the Treatment notes.

Plan

The structured outline of ongoing management, follow-up, and next steps for the Patient.

• Click on the Plan panel.

• The Plan panel will expand.

• Click on the text field to enter the Plan notes.

Nurse Instruction

Specific clinical directions given to nursing staff regarding the Patient’s care.

• Click on the Nurse Instruction panel.

• The Nurse Instruction panel will expand.

• Click on the text field to enter the Nurse Instruction notes.

• Click on the Finalise All Stages button to finalise all the sections on the Doctor Note.

• All panels will now display a green Completed icon.

Quick Action Buttons

Additional options that are available on the Clinical screen.

• For more information on using the Quick Action Buttons, please refer to the user manual: Workflow Event Options.