The Consultation Note

• Records all changes in the patient consultation notes, including the name of the person making the changes, the time of the changes, and the location of the changes.
• Obstetrics/Gynaecology and Social History, because of their structure, have a History button on their individual pages to track changes.

• Text Shortcuts can be created for each section. These can be general or specific (e.g., diabetes, gynecology, cardiology). If you would like to learn about Text Shortcuts, read this article.
• In addition, you can also type in any of the 4 Textboxes in the section.

• The Medical History button has 8 sections (Diagnosis, Allergies, Past/Current Medications, Past Medical History, Surgical History, Immunizations, Family History, Social History) where you can create various types of medical history or use the @trigger in the respective textbox to search specifically for what you want to add.
  • • The @ trigger will not work for Social History, Family History, or Obstetrics/Gynaecology.
    • This article explains how the @trigger it works

There are 2 buttons on the Objective section: Point of Care Tests and Documents.

• Read this article to understand how Point of Care Test are created.
• Documents uploaded can be shared with the Patient Portal.

• • Assessment Extras: Diagnosis, Symptoms, and Differential Diagnosis dropdowns with ICD-10 Codes. The most RECENT selections are shown at the top of each dropdown, and you can select more than one item within these 3 sections.

• The Diagnostic Tests button lets you create orders that are for 3^rd party labs.
  • Read this article to understand how Diagnostic Tests are created.
• The Medications & Procedures section has 4 sections: Prescriptions, Administered Medications, Immunizations, and Procedures, where you can create information for these 4 sections.
  • The @trigger also applies here, and this article explains it.

• Post Visit Instructions: In this section, click the Add Instructions button and create your own Post Visit instructions in the textbox (which can be saved for approval by an Admin) or use one of the approved templates, which are suggested based on the Diagnoses (Assessment Extras) or Procedures (Plan) saved. When you are finished, you can Download, Print, or Send it to the Patient. Also, see the Post Visit Instructions article for instructions on creating them.