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Record Today's Notes

Additional information about recording notes is included in Frequently asked questions about the patient record.

Patient notes are recorded from the Today's Notes section in the patient record.

Today's Notes

What's the best way to record notes?

There are three ways of manually adding notes:

You can use a combination of all three methods to enter notes. Bp Premier will also automatically add notes as a result of information recorded by the provider in other areas of the patient record and software, such as completing a health assessment, or sending a HL7 ereferral.

Keyboard and autofill shortcuts for notes

The following keyboard shortcuts are useful for navigating the left hand patient tree. Press the keyboard combination to switch to that component of the tree.

Keyboard shortcut

Go to

Shift+F4

Open medical certificate template in word processor

Ctrl+Alt+T

Today's notes

Ctrl+Alt+V

Past visits

Ctrl+Alt+X

Current Rx

Ctrl+Alt+H

History

Ctrl+Alt+I

Immunisations

Ctrl+Alt+R

Investigation Reports

Ctrl+Alt+C

Correspondence Out

Ctrl+Alt+N

Correspondence In

Ctrl+Alt+P

Past prescriptions

Ctrl+Alt+O

Observations

Ctrl+Alt+F

Family/Social

Ctrl+Alt+Y

Obstetric

Ctrl+Alt+S

Pap smears

Ctrl+Alt+E

EPC

Ctrl+Alt+A

Health assessments

Ctrl+Alt+L

Care plans

Ctrl+Alt+M

Medication reviews

Ctrl+Alt+D

Diabetes cycle of care

Alt+D or Alt+G

Open Diagnosis window

Autofill entries allow a provider to enter text using a shortcut of only a few letters. Type the shortcut text into Today's Notes and press Enter to substitute the full text. The following shortcuts are already available.

Autofill shortcut

Description

PC

Presenting complaint:

HX

History:

OE

Examination:

MX

Management:

DX

Diagnosis:

RV

Review interval:

S:

Subjective:

O:

Objective:

A:

Assessment:

P:

Plan:

AX

Actions:

You can create your own autofill shortcuts. See Autofills for more information.

By default, Today's notes shows a standard SOAP heading structure (Subjective, Objective, Assessment, Plan). To turn this off, go to the Clinical tab of the User Preferences screen and disable Load SOAP headings on opening notes.

History and examination

The History and Examination tools on the right hand side of the patient record comprehensively record particulars of a patient's condition, including images to indicate placement.

History and examination

Double-click on any of the icons to open the History & Examination screen. Select a tab from the right hand side of this screen to record notes for different systems.

Most of the fields in the History & Examination screen are self-evident, and require you to tick a checkbox, enter free text, or select from a dropdown.

Create a descriptive diagram

Some tabs offer a graphic of an area of the body. For example, from the Skin tab , you can edit diagrams that represent the entire skin surface: head, body, hands and feet.

  1. Click on the graphic to open the diagram editor.
  2. History and Examination Diagram Editor

    The first toolbox of icons offers different ways of marking the image, such as cross-hatching, circles, stitches, or squares. The second toolbox selects the colour to use for the marking.

  3. Select a colour, markup type, and Pen size, and mark the image to graphically indicate the condition.
  4. Click Undo to undo the latest change, or click Clear to clear all marking and start again.
  5. Click Save Diagram in the top right to save the image.
  6. Click Save to save the History and Examination details and write the information to Today's notes.

Button toolbar

The buttons along the bottom of the clinical record add significant details or related information.

IMPORTANT  Your practice's policy will determine if free text diagnoses and reasons for visit are allowed. It is good practice to always use coded conditions for diagnoses. Bp Premier provides a cleanup tool for converting past history free text diagnoses into coded conditions.

Button

Description

Diagnosis

Records a coded diagnosis for the patient, which can be added to past history and uploaded to the patient's My Health Record.

Procedure

Records a medical procedure for the patient, which can be added to past history and uploaded to the patient's My Health Record.

Reason for visit

Records a reason for visit. Details are similar to Diagnosis.

If you have recorded a Diagnosis or Procedure and ticked Save as Reason for visit, there is no need to also record a reason for visit.

Review

Books a prospective followup appointment for the patient.

Autofill

Opens autofilll options for notes.

Past visits

Opens all of the patient's past visits in a single printable document. Confidential visits are not included.

Last visit

Opens the patient's last visit from the Past visits section. Past visits can be appended. See Search past visits for more information.

You can also add and delete reasons for visit by right-clicking in the Reason for visit list above the notes section. For same-day notes, you can also Edit from the right-click menu.

Reason for Visit context menu