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Clinical Notes, Bodycharts, Attachments & Appointment Notes
Clinical Notes, Bodycharts, Attachments & Appointment Notes

Learn how to take notes in Better Clinics

Trentenn avatar
Written by Trentenn
Updated over 2 years ago

Note taking is an essential part of running a health clinic. Being able to quickly add and secure notes against team members, clients or appointments is a must have. Better Clinics allows you to do all of this and more.

Types of Notes you can add to Better Clinics:

  • Clinical notes - including text, episodes & discharge, links & treatment symbols.

  • Body charts - add your own or use our library. Complete drawing & annotations.

  • Attachments - securely upload and store attachments & photos.

  • Calendar notes - add notes related to a particular appointment for team sharing.

  • Handover notes - add handover notes so the clinical team are over all the details.

  • Invoice notes - add notes to invoices, easily access these under respective client.

  • Physitrack Programs - Better Clinics is integrated with Physitrack. Learn more >

Clinical Notes

Adding clinical notes in detail against a client is fast and easy. In Better Clinics there are New Note's and Read Note's.

  • New Note - Add a new typed note, note template, attachment or Body chart.

  • Read Notes - Read any existing notes on the client file.

How to Add a Clinical Note:

  1. Select the client. You can do this by going to Clients > Client List > Select Client or click on the client's name from a calendar appointment

  2. Once the client is selected, click 'Notes' in the sub-banner.

  3. Click 'New Note' (this is the default view).

  4. Using the dropdown menu, Select the Team Member writing the note. By default this will show the logged in user. However as some clinics share logins (e.g. Reception) if a team member is on a shared device they can select their name for the note. This allows for flexible clinic arrangements.

  5. Select the 'Consent' checkbox. This will be added into the textbox.

  6. Date of Note: (default is today, this can be edited if the note was for an appointment on a different day, or can also be edited later). If the team member edits a draft note or final note the date will display as originally saved against the note.

  7. Episode: Create a new episode or select from an existing client episode. Episodes in health care are a series of appointments or treatment events for an injury. Therefore when a note is added, the note can be assigned to an Episode. Assigning a note to an episode is optional.

  8. Add a new Episode: Click '+Add new'. Add Episode name, date, description and tags/categories. Save

  9. Better Clinics has notes Autosave. When typing Better Clinics will autosave a new note - both text notes or note templates. These are saved as Draft until they are saved as Final.

  10. Draft vs Final Notes -

    1. Draft notes can be saved and then can be edited easily before they are finalised and marked as final.

    2. Final notes have been marked as Final and are locked. To unlock Final notes, if Note Authentication is on in Settings, the password of the Team Member who wrote them will be needed to unlock them before editing. This is a note security feature of Better Clinics.

  11. SEARCH & FILTER SIDEBAR for READ NOTES: Within the sidebar filter notes by Team Member or Episode.

Tip: Record when you complete notes! Better Clinics allows you to record when you have completed your clinical notes for each of your clients with ease from the calendar page. This may be used to help track what notes you still need to complete or what notes have already been completed! When you have completed the notes, go to the client's appointment in the calendar and launch the appointment pop up screen. Select the toggle to the left of the Clinical Notes button to mark your notes as done as shown in the image below.

Tags

Use tags to group and sort your clients and notes. Adding a tag to your notes is an easy way to search for a particular note.

To Add a Tag:

  1. Select a Client > Notes > New Note

  2. In the "Tags" text box add your chosen Tag. You can add multiple tags to your note. Separate your tags by clicking the return/enter key on your keyboard.

  3. Save either as a Draft or as Final

Bodycharts

Better Clinics offers bodycharts in their 'Body Chart Library' for you to use or you can also add your own bodycharts. Mark up bodycharts on any device to keep accurate annotations for all clients and appointments.

How to use Bodycharts:

  1. Select a Client > Notes

  2. New Note > Bodychart

  3. Select Team Member, Date and Episode like any other note format

  4. Select from the Better Clinics Bodychart image library or add a new image to use for this client.

  5. The bodychart image will load into full page view. There is an editor at the top of the bodychart screen where you can select the drawing and text tools to mark up the body chart. Add the markup to the bodychart.

  6. Once done, click 'Save'.

  7. The Bodychart will be saved to the client record. You can edit it at any time.

Attachments & Uploads

It's important for a busy clinic to have all critical data in one system and PMS. With Better Clinics you can add any attachments to a client record, ensuring a comprehensive record keeping protocol.

In Better Clinics you can add images, photos and documents securely. Learn more about attachments and uploads >

How to add attachments:

  1. Search and select a Client > Notes

  2. New Note > Attachment

  3. You can either Browse for the file by clicking on the 'Click to Upload' button, or you can simply drag the attachment over the drop canvas and the attachment will start to upload securely to your Better Clinics account.

  4. When adding attachments, you also have the option of adding the team member and date. The default is the logged in team member, today's date and a Description.

  5. Save

  6. Once the attachment has been uploaded, a file preview will be available and you can click to download and view the file.

Calendar Notes

If you want or need to add some detail about a particular appointment you can add an appointment note directly to the calendar. When you do, this will also be added to the client notes section so you've got a track on it at any time. 

How to Add a Calendar Note:

  1. Create a new appointment. If you would like to add a note to a pre-existing appointment, click on the Appointment you would like to add a note to and click the green 'Edit' button.

  2. Add notes in the 'Notes' text section

  3. Click 'Save'

  4. The note will be saved against the appointment and the client.

Team Handover Notes

Team member communications between therapists is critical for a smooth running clinic. Better Clinics has Team Handover notes where a central noticeboard can be used to communicate handover notes to each team member. This might be on clients, meetings, business operations etc. 

How to add a Team Handover Note:

  1. Go to Day View in the calendar 

  2. Each Team Member has their own column. 

  3. At the top of each column there is a Note Pad icon in the colour Grey. 

  4. Click on the 'Note Pad' Icon

  5. A pop up will display, add your notes. 

  6. Click 'Save'. 

  7. The note will be added to the Team Member column as selected. 

  8. When a note is there it will appear RED. 

  9. Click at any stage to Read, Edit or Delete.

Invoice Notes

There are times when you will need to make a note against a particular Client Invoice.

How to add an Invoice Note:

  1. Before completing, select Advanced Options > Add Note

  2. Add the note and Save

  3. The Invoice note will be saved and can be viewed on the Invoice.

Export Notes

In Better Clinics you have the ability to Export your client notes as a PDF.

To Export your Client Notes:

  1. Select a Client > Notes > Read Notes

  2. Select the note you would like to export by clicking on the square box on the right hand side of the episode name. To export more than one note a time, select multiple notes by clicking the corresponding square box. To select all client notes, click the square box besides the export button.

  3. Click the export button at the top right hand corner below the Client's name.

  4. A PDF of the notes will then be downloaded for you to use.


Tags: SOAP notes, Clinical notes, appointment notes, attachments, uploads

More:
Customise your Clinical Note Templates
How Better Clinics manage uploads and attachments

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