Clinical Notes

To create Clinical Notes:

Home → Healthcare → Clinical Note → New
(or Inpatient Record → Create → Clinical Note)

During an inpatient stay, practitioners conduct regular rounds and document progress:

• Daily clinical notes via Patient Encounters linked to the Inpatient Record

• Multiple encounters per admission — each round creates a new encounter

• Vital signs recorded at regular intervals

• Nursing notes captured through nursing tasks

  

  

Documentation During Admission

Document	Purpose	Frequency
Patient Encounter	Doctor's round notes, orders	Daily or as needed
Vital Signs	Temperature, BP, pulse, etc.	Every 4-8 hours
Nursing Tasks	Care activities completed	As ordered
Medication Entry	Drugs administered	As per schedule