Progress Notes are clinical notes regarding a patient’s visit. Due to the legality of the clinical note as an accurate record of treatment, care should be taken to enter the information correctly from the start.
Once a Progress Note has been entered to the patient record, it may be amended or edited only on the day it was entered.
o Click on the icon for Edit.
o The details of the existing progress note appear on the screen.
o Edit the necessary information
o Click the Save Notes button.
Once the current date has passed, or if the note has been signed, the progress not cannot be amended or edited. It may, however, be stricken through, and the information re-entered.
o To strike off a note, click on the icon for Edit for the note which is to be edited.
o The details of the existing progress note appear on the screen.
o Click the Strike-off Notes button.
o If the note is to be retained as entered, the Cancel button.
o A stricken note can be returned to normal by removing the strike-off. To remove the strike-off line, click the word Edit for the desired note. Click the Restore Notes button to remove the strike-off.
o Stricken notes remain in the patient record, and will be indicated with a line through the text.