Clinical Notes

Clinical Notes can be added to the Patient's record when adding treatment. There are two methods for adding clinical notes:

1) SOAP system - History (subjective), Examination (objective), Diagnosis (assessment) & Plan.

2) Clinical Protocols - Practices can setup their own 'Clinical Protocols' for their users to follow.

To setup your own protocols, an MWI Implementation Consultant can guide you through this process. Contact your BDM or support@mwiah.co.uk for further information.

This page documents both methods of adding clinical notes.

Clinical Notes - SOAP

Adding a Clinical Note

1) Enter the Treatment Screen and select the 'Add Treatment' tab.

2) Select the 'Clinical' button'.

3

Once Clinical Notes has been selected, the below window will appear with a list of Clinical Note protocols. These protocols assist the user with typing their clinical notes.

Double-click on the required Clinical Note protocol. For this example, we are using the Vet Consultation protocol.

For information on adding/configuring Clinical note protocols see the Treatment Administration page.

Once you have selected a protocol, the Clinical Notes screen will load.

The user can now insert clinical notes in the boxes provided.  Start typing the notes in the History section, to move to the next box, press tab on your keyboard or use the mouse to move to the next section. You do not have to complete all the boxes, boxes which remain empty are not saved into the patient history.

Note

If you need a clinical note to stand out from the standard blue font, insert a * in front of the subject heading: i.e. *History then write your content. The note will show up in a red font.

Certain protocols do not require free text, instead the option to provide an answer is available. The user can select an answer from the drop-down list and this will populate the question box.

Users can also select a Clinical Code from the list provided.

Saving Clinical Notes

Once you have completed typing your Clinical Notes press the "Save and Exit" button at the bottom of the clinical note screen.

Once the notes are saved they will appear in the "Draft" Items of the Add Treatment screen.

Speech to Text

Where the browser supports Speech to Text (currently Google Chrome) you can use your microphone attached to your computer to record your clinical notes.

This speech-to-text feature uses services available directly within your browser and is transmitted to services by the browser vendor.  Please note that no audio spoken is transmitted to or stored within Merlin.

When adding clinical notes, you will see a microphone button for each question.

On first use, select ‘Agree’ to the disclaimer message.

Select the microphone icon to begin recording. Once selected, the microphone button will appear red to indicate voice recording is in process.

Once you have finished speaking, select the red microphone button to stop recording. Your speech will then be converted into text.

Please check the text for accuracy before saving content into the Patient’s history.