08 Nov How to save time completing clinical notes
One of the most important legal and ethical aspects of a clinician’s job is to take and keep accurate notes on every interaction with a patient. This obligation doesn’t end with the taking of notes, the safe and secure storage of patient files, digital and hard-copy is strictly governed by various Government and industry bodies in Australia.
Taking notes should never be a burden on the health professional nor come at the expense of patient interaction, however that is being seen more and more in health fields as paperwork requirements change or become greater. Different studies have put the time clinicians spend on client notes and administrative tasks at up to one third of their entire day.
Thankfully, there are a number of ways you can streamline your note-taking and file storage systems and taking your clinical notes digital is a major step in the right direction. Here’s how you can use clinical note software to your advantage and save some precious time in the process:
- Customise your templates
Everybody has their own way of doing things and digital clinical note software with customisation and automatic settings are going to save you plenty of time. Set yourself automatic templates for new clients or any other scenario to save yourself having to write out the same old thing for each appointment.
- Speak your notes
Simultaneously getting to know a new patient’s medical history, building rapport, taking them through a new program and writing in-depth clinical notes is all in an appointment’s work for a clinician, but there is an easier way. By removing the pen and paper we can remove looking down and away from your patient for a third of the appointment. Speak your notes with Cliniknote and you’ll not only help to reinforce the patient’s details in your own mind, but repeating it out loud allows your patient to retain more information, increasing their chances of following all of your prescriptions.
- Organise and categorise your files your way
Physical storage systems are so rigid can be difficult to navigate depending on the information you are looking for. With digital clinical notes backed up on the cloud, you can choose to organise and label your files any which way you choose. You can have filing systems tagged for different purposes, making it much faster to switch between patients and search for large amounts of data that would otherwise take plenty of time to dig for.
One thing that medical professionals are (rightly) concerned about when moving to a digital notes platform is making sure nothing gets lost or missed. Well, thanks to the auto-save function with Cliniknote and the handy end-of-day tracker, anything missed during the day won’t be lost and will be picked up before the close of business.
- Take and edit photos on your iPad
Who likes taking photos of patients, fumbling with cables and uploading it to the computer or having to scan it to the patient’s other medical professionals? Because Cliniknote is built for native iPad functionality, you can take photos straight from your tablet and add them directly to your patient’s file or edit right then and there with no need for any other software. You can then easily share these with your patients and they can send progress shots for their file or they can be added to their digital record.
Clinical note taking doesn’t have to be a time consuming exercise or one that takes up precious office space. Free yourself and your administration staff to get stuck into the people centric aspects of running a practice.