Clinical Visits and Notes

CLINICAL_VISITS.md

Clinical Visits and Notes

Complete guide to documenting patient consultations, clinical notes, diagnoses, and treatment plans in MyClinicSoft.

Overview

The Clinical Visits system allows healthcare providers to:

  • Document patient consultations
  • Record vital signs and examination findings
  • Add diagnoses using ICD-10 codes
  • Create treatment plans
  • Generate medical certificates
  • Track visit history
  • Integrate with prescriptions and lab orders

Accessing Clinical Notes

Navigate to Clinical Notes from the main menu.

View Options:

  • All visits (default)
  • Today's visits
  • My visits (current doctor only)
  • Filter by patient, doctor, or date range
  • Search by diagnosis or chief complaint

Creating a New Visit

Starting a Visit

From Appointment:

  1. Go to Appointments
  2. Click on appointment
  3. Click Start Visit
  4. Visit form opens with patient and doctor pre-filled

From Patient Record:

  1. Go to Patients
  2. Select patient
  3. Click New Visit
  4. Select doctor
  5. Visit form opens

Direct Entry:

  1. Go to Clinical Notes
  2. Click New Visit
  3. Select patient and doctor
  4. Fill in visit details

Visit Information

Basic Details

  • Patient* (required) - Auto-filled from appointment/patient page
  • Doctor* (required) - Default to logged-in doctor
  • Visit Date and Time* (required) - Defaults to current date/time
  • Visit Type
    • New Patient Consultation
    • Follow-up Visit
    • Emergency Visit
    • Routine Check-up
    • Procedure
    • Sick Visit
    • Wellness Visit

Chief Complaint

  • Chief Complaint* (required)
    • Primary reason for visit
    • Patient's own words
    • Brief description

Examples:

  • "Headache for 3 days"
  • "Cough and fever"
  • "Follow-up for hypertension"
  • "Routine annual checkup"

History of Present Illness (HPI)

Detailed narrative of the presenting problem:

Components:

  • Onset - When symptoms started
  • Location - Where the problem is
  • Duration - How long it has lasted
  • Character - Quality/description
  • Aggravating factors - What makes it worse
  • Relieving factors - What makes it better
  • Timing - Pattern or frequency
  • Severity - How bad it is (scale 1-10)
  • Associated symptoms

Example:

Patient reports headache starting 3 days ago, located in frontal region.
Describes as throbbing pain, severity 7/10. Worse with bright lights and
noise. Partially relieved by rest and darkness. Associated with nausea
but no vomiting. No fever or vision changes.

Review of Systems (ROS)

Systematic review of body systems:

Systems:

  • ✅ Constitutional (fever, weight loss, fatigue)
  • ✅ Eyes (vision, pain, discharge)
  • ✅ Ears/Nose/Throat (hearing, congestion, sore throat)
  • ✅ Cardiovascular (chest pain, palpitations, edema)
  • ✅ Respiratory (cough, shortness of breath, wheezing)
  • ✅ Gastrointestinal (nausea, abdominal pain, bowel changes)
  • ✅ Genitourinary (urination, discharge)
  • ✅ Musculoskeletal (joint pain, muscle weakness)
  • ✅ Skin (rash, lesions, itching)
  • ✅ Neurological (headache, dizziness, seizures)
  • ✅ Psychiatric (mood, anxiety, sleep)
  • ✅ Endocrine (temperature intolerance, thirst)
  • ✅ Hematologic (bleeding, bruising)
  • ✅ Allergic/Immunologic

For Each System:

  • Check "No symptoms" or
  • Document positive findings
  • Note severity and duration

Vital Signs

Record patient vital signs:

Standard Vitals:

  • Blood Pressure (mmHg)
    • Systolic / Diastolic
    • Example: 120/80
    • Flag: High (>140/90), Low (<90/60)
  • Heart Rate (bpm)
    • Normal: 60-100 bpm
    • Flag: Tachycardia (>100), Bradycardia (<60)
  • Respiratory Rate (breaths/min)
    • Normal: 12-20/min
    • Flag: Tachypnea (>20), Bradypnea (<12)
  • Temperature (°C or °F)
    • Normal: 36.5-37.5°C (97.7-99.5°F)
    • Flag: Fever (>38°C/100.4°F), Hypothermia (<36°C/96.8°F)
  • Oxygen Saturation (%)
    • Normal: 95-100%
    • Flag: <95%

Additional Measurements:

  • Weight (kg or lbs)
  • Height (cm or inches)
  • BMI - Auto-calculated from weight/height
    • Normal: 18.5-24.9
    • Underweight: <18.5
    • Overweight: 25-29.9
    • Obese: ≥30
  • Pain Scale (0-10)
    • 0 = No pain
    • 1-3 = Mild
    • 4-6 = Moderate
    • 7-10 = Severe

Automatic Alerts:

  • System flags abnormal vitals
  • Shows in patient record
  • Alerts appear in dashboard

Physical Examination

Document examination findings:

General Appearance:

  • Well-appearing / Ill-appearing
  • Alert and oriented
  • In no acute distress / In distress
  • Age-appropriate

Examination by System:

Use templates or free-text entry for:

  • HEENT (Head, Eyes, Ears, Nose, Throat)
  • Neck
  • Cardiovascular
  • Respiratory
  • Abdomen
  • Musculoskeletal
  • Neurological
  • Skin
  • Psychiatric

Template Example (Cardiovascular):

Regular rate and rhythm, no murmurs, rubs, or gallops.
S1 and S2 heard. No peripheral edema. Pulses 2+ bilaterally.

Templates Available:

  • Normal examination templates
  • System-specific templates
  • Specialty templates
  • Custom templates (create your own)

Diagnoses

Add diagnoses with ICD-10 codes:

Adding a Diagnosis:

  1. Click Add Diagnosis
  2. Search by:
    • Disease name
    • ICD-10 code
    • Symptoms
  3. Select from results
  4. Set type:
    • Primary diagnosis
    • Secondary diagnosis
    • Rule-out diagnosis
  5. Add notes if needed

ICD-10 Search Examples:

  • "hypertension" → I10: Essential (primary) hypertension
  • "diabetes" → E11: Type 2 diabetes mellitus
  • "asthma" → J45: Asthma
  • "pneumonia" → J18: Pneumonia

Multiple Diagnoses:

  • Add as many as needed
  • First one is primary
  • Drag to reorder
  • Mark as chronic condition

Diagnosis Details:

  • Severity (mild, moderate, severe)
  • Status (active, resolved, chronic)
  • Onset date
  • Notes

Assessment and Plan

Document your assessment and treatment plan:

Assessment:

  • Summary of findings
  • Clinical reasoning
  • Differential diagnoses considered
  • Diagnostic impression

Plan: Organize by category:

  1. Medications

    • Link to create prescription
    • List new medications
    • Changes to existing medications
    • Medication stopped

  2. Laboratory/Diagnostic Tests

    • Link to order lab tests
    • Tests ordered
    • Reason for tests
    • When to perform

  3. Procedures

    • Procedures performed today
    • Procedures to schedule
    • Referrals needed

  4. Education

    • Patient education provided
    • Resources given
    • Lifestyle modifications

  5. Follow-up

    • When to return
    • What to monitor
    • When to call clinic

Example Plan:

1. Start Lisinopril 10mg daily for hypertension
2. Order lipid panel and HbA1c
3. Advised on DASH diet and exercise
4. Follow-up in 2 weeks to check BP and review labs
5. Call if BP >140/90 or symptoms worsen

Clinical Notes

Free-text clinical documentation:

Clinical Notes Section:

  • Additional observations
  • Patient questions and answers
  • Family concerns
  • Social context
  • Treatment preferences

Tips for Good Documentation:

  • Be clear and concise
  • Use medical terminology appropriately
  • Document relevant negatives
  • Note patient's understanding
  • Record consent for procedures

Visit Documents

Attach documents to visit:

Document Types:

  • Images (photos of lesions, injuries)
  • External reports
  • Consent forms
  • Procedure notes
  • Referral letters

Upload:

  1. Click Attach Document
  2. Select file
  3. Add description
  4. Click Upload

Saving and Completing Visit

Save Options

  • Save Draft - Save and continue editing later
  • Save and Close - Complete visit and close
  • Save and Print - Save and print visit summary

Auto-save:

  • System auto-saves every 2 minutes
  • Prevents data loss
  • Recovery available if browser crashes

Visit Status

  • Draft - In progress, can be edited
  • Completed - Visit finalized, appears in patient history
  • Amended - Visit edited after completion (audit trail maintained)

Viewing Visit History

Visit List

View all visits for a patient:

  1. Go to patient detail page
  2. Click Visit History tab
  3. See chronological list of visits

Display:

  • Visit date
  • Doctor
  • Chief complaint
  • Diagnoses
  • Status

Actions:

  • View visit details
  • Print visit summary
  • Copy to new visit (use as template)
  • Amend visit (if needed)

Visit Detail View

Click on any visit to see:

  • Complete visit documentation
  • Vitals flowsheet
  • Diagnosis list
  • Treatment plan
  • Linked prescriptions
  • Linked lab orders
  • Visit timeline

Medical Certificates

Generate medical certificates from visits:

Creating Medical Certificate

  1. Open visit
  2. Click Generate Medical Certificate
  3. Fill in certificate details:
    • Patient name (auto-filled)
    • Diagnosis (auto-filled)
    • Recommendations
      • Rest for X days
      • Unfit for work/school
      • May resume activities
    • Certificate date
    • Doctor signature
  4. Click Generate

Certificate Includes:

  • Clinic letterhead
  • Patient information
  • Visit date
  • Diagnosis
  • Medical recommendations
  • Doctor's name and license number
  • Doctor's signature
  • Official clinic seal

Uses:

  • Work/school excuse
  • Insurance claims
  • Disability applications
  • Court/legal purposes

Managing Certificates

Print:

  • PDF format
  • Professional layout
  • On clinic letterhead

Send:

  • Email to patient
  • Include in patient portal

Track:

  • All certificates logged
  • Audit trail maintained
  • Reprint anytime

Lab Request Forms

Order laboratory tests from visit:

Creating Lab Order

  1. During visit or from completed visit
  2. Click Order Labs
  3. Select tests:
    • CBC (Complete Blood Count)
    • Chemistry panel
    • Lipid panel
    • HbA1c
    • Urinalysis
    • Custom tests
  4. Add clinical indication
  5. Mark as STAT if urgent
  6. Click Create Order

Lab Request Form Includes:

  • Patient demographics
  • Tests ordered
  • Clinical indication
  • Ordering doctor
  • Date ordered
  • Special instructions

Actions:

  • Print for patient (if external lab)
  • Send to integrated lab
  • Track results in Lab Results section

Visit Templates

Create templates for common visit types:

Using Templates

  1. Click New Visit
  2. Select Use Template
  3. Choose template:
    • Annual Physical
    • Hypertension Follow-up
    • Diabetes Check
    • Well-child Visit
    • Post-op Check
  4. Template populates form
  5. Edit as needed

Creating Custom Templates

For doctors with permission

  1. Complete a visit
  2. Click Save as Template
  3. Name template
  4. Select what to include:
    • ROS sections
    • Physical exam sections
    • Common diagnoses
    • Standard plan
  5. Click Save Template

Template Uses:

  • Save time on similar visits
  • Standardize documentation
  • Ensure completeness
  • Train new staff

Visit Amendments

Correct or add to completed visit:

When to Amend

  • Correct documentation error
  • Add missed information
  • Clarify unclear notes
  • Update based on additional info

How to Amend

  1. Open completed visit
  2. Click Amend Visit
  3. System creates addendum entry
  4. Make changes
  5. Add reason for amendment
  6. Click Save Amendment

Amendment Tracking:

  • Original visit preserved
  • Changes highlighted
  • Amendment timestamp
  • Reason documented
  • Audit trail maintained

Note: Cannot delete visits, only amend. This maintains legal compliance.

Integration with Other Features

Prescriptions

From visit, create prescriptions:

  1. Click Create Prescription
  2. Patient and doctor auto-filled
  3. Add medications
  4. Save prescription
  5. Prescription linked to visit

Lab Results

Lab orders from visit automatically link:

  • View pending labs
  • See completed results
  • Results appear in visit record

Billing

Generate invoice from visit:

  1. Click Create Invoice
  2. Services auto-filled from visit
  3. Add medications/procedures
  4. Calculate total
  5. Save invoice

Follow-up Appointments

Schedule follow-up directly:

  1. Click Schedule Follow-up
  2. Select recommended timeframe
  3. Choose date/time
  4. Save appointment
  5. Patient notified

Visit Reports and Analytics

Available Reports

Navigate to Reports → Clinical

Reports:

  • Visits by date range
  • Visits by doctor
  • Visits by diagnosis
  • Patient encounter frequency
  • Average visit duration
  • Common diagnoses
  • Chief complaints analysis

Charts:

  • Visit volume over time
  • Diagnosis distribution
  • Doctor productivity
  • Visit types breakdown

Tips for Effective Documentation

  1. Document in Real-Time - Write notes during or immediately after visit
  2. Be Specific - Include details that matter
  3. Use Templates - Save time while maintaining completeness
  4. Record Pertinent Negatives - Note what wasn't present
  5. Write for Others - Someone else may need to read your notes
  6. Include Patient Education - Document what you taught
  7. Note Follow-up Plan - Clear instructions for patient and staff
  8. Review Before Finalizing - Check for completeness and accuracy
  9. Use Structured Format - Follow SOAP or HPIP format consistently
  10. Sign and Date - Finalize visits promptly

SOAP Notes Format

Optional structured format:

S (Subjective):

  • Chief complaint
  • History of present illness
  • Review of systems
  • Patient's perspective

O (Objective):

  • Vital signs
  • Physical examination findings
  • Lab results
  • Imaging results

A (Assessment):

  • Diagnoses (ICD-10)
  • Clinical reasoning
  • Differential diagnoses

P (Plan):

  • Medications
  • Procedures
  • Tests ordered
  • Follow-up
  • Patient education

Mobile Access

Access visits on mobile devices:

Mobile Features:

  • View visit history
  • Quick visit documentation
  • Voice-to-text for notes
  • Capture photos
  • Review pending visits
  • Complete visits

Troubleshooting

Cannot Save Visit

Possible Causes:

  • Missing required fields
  • Internet connection lost
  • Session expired

Solutions:

  • Check for red field indicators
  • Verify internet connection
  • If session expired, copy notes and re-login
  • Use auto-save recovery

ICD-10 Code Not Found

Solutions:

  • Try different search terms
  • Use symptom-based search
  • Browse by category
  • Add custom diagnosis (admin approval needed)

Templates Not Loading

Solutions:

  • Refresh page
  • Check browser compatibility
  • Clear cache
  • Contact IT support

Best Practices

  1. Timely Documentation - Complete within 24 hours
  2. Accurate Vitals - Double-check measurements
  3. Complete ROS - Don't skip systems
  4. Specific Diagnoses - Use exact ICD-10 codes
  5. Clear Plans - Patient should understand next steps
  6. Link Records - Connect prescriptions, labs, referrals
  7. Professional Language - Medical terminology, no slang
  8. Objective Tone - Facts, not opinions
  9. Legibility - Clear writing or typing
  10. Compliance - Follow documentation standards

Legal Considerations

Documentation Standards:

  • All visits must be documented
  • Maintain objectivity
  • Include informed consent
  • Note patient non-compliance
  • Document communications
  • Preserve confidentiality

Medical-Legal Protection:

  • Complete documentation protects you
  • "If it's not documented, it wasn't done"
  • Amendments must be transparent
  • Never alter original records
  • Maintain audit trail

Related Documentation