Clinical Summary
Overview
ICANotes+ enables practice users to generate clinical summaries for their clients. Much like other notes, users can construct a clinical summary, compile it, and capture the clinician's electronic signature. Clinicians have the ability to input narratives that will be included in the compiled note. Within the clinical summary, users can incorporate medical history, diagnoses, adverse drug reactions, medications, and vital signs.
Settings for Clinical Summary
You must first select the Clinical Summary checkbox in the Note Settings within the Practice Settings and Personal Preferences sections. Refer to the following screenshots.
Go to the Personal Preferences section, click the Note Settings tab from the top, and then select the Note Settings option from the left side bar as shown below.
Select the applicable checkboxes for the Clinical Summary note type from the following screen. When you create a clinical summary, you can compile the note for the selected details you have recorded for the clients.
Navigating to Clinical Summary
There are two locations you can navigate to the clinical summary note for the clients.
- Client’s Chart Face
- Within the Notes
Navigating to Clinical Summary from Chart Face
When accessing client's chart face, you can locate the Clinical Summary button in the notes section as highlighted in the screen below.
Navigating to Clinical Summary within the Notes
When accessing the note (for example, Progress Note in this case), you can locate the Clinical Summary button on top after compiling the note, as highlighted in the screen below.
Information Contained in the Clinical Summary
The following information is contained in the clinical summary. To view the following details on the clinical summary, you must compile the respective note. If you have not compiled the note, the details won't appear within the clinical summary.
- Medical History: In the Complete Evaluation note, when you record any medical history details, they will appear in the clinical summary.
- Diagnosis: When you access notes within ICANotes+, there is an option to record the diagnosis codes. All the diagnosis codes you have recorded in any of the notes, they will appear in the clinical summary.
- Adverse Drug Reactions: The practices who have turned on the eRx feature can include the adverse drug reactions in the clinical summary if they have recorded these details for the clients within the eRx module.
- Medications: The practices who have turned on the eRx feature can include the medication details in the clinical summary if they have prescribed them for the clients within the eRx module.
- Vital Signs: In the Progress Note, when you record details within the Vital Signs section, they will appear in the clinical summary.
Clinician’s Narrative
Clinicians can enter the narratives in this section and they will appear on the clinical summary section at the bottom when they compile the note.
Below is a screenshot of the compiled note that displays the clinician's narratives at the bottom of the note.
Address Clinical Summary to Related Contact
When compiling the clinical summary, you can address it to the desired contact. You can select the contact from the Clinical Summary Addressed to dropdown as highlighted in the screen below.
Note: When you expand the Addressed To dropdown, it displays only the medical related contacts.
If the desired contact is not available in the list, you can click the Add Related Contact option as shown below.
This opens the Create New Contact screen. When you save the contact, it appears in the Clinical Summary Addressed to dropdown.
Preview for Clinical Summary
When you select the Yes option for the respective option as shown in the screen below, it will preview the content you have recorded for the client in the Preview pane on the right side.
Compiled Clinical Summary
When you create the clinical summary and click the Compile and Preview button, the compiled note appears as shown in the screen below.
You can capture electronic signature on the compiled note by clicking the Electronic Sign button as highlighted in the screen below.
FAQs
You can find the Frequently Asked Questions (FAQs) on our Knowledge Base page.
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