Managing Patient Records: Progress Notes
Select your patient by clicking on their name to open the record and click the Progress tab in the left side menu. To create a new progress note, click on the New Progress Note button. The New Progress Note pop-up box appears (Figure 1).
Figure 1: The New Progress Note box
First, select the reason for contact from the drop down list. The Reason for Contact drop down list will bring up items from the patient's medical history, using a terminal database called SNOMED-CT. If the presented reason is not available from the given list, you can select Other from the list and type the new reason in the text box (Figure 2).
Figure 2: Adding a new reason for contact
Enter your progress note in the big text box at the bottom. To save the progress note, click on the Save button at the top of the screen. A progress note can be edited for 4 hours after saving. After this period, you can apend other notes to the note at a later date.