Creating and managing your clinical notes is a straightforward process in OS for Health Business. These can be managed directly from within the Client Record Profile as described below.
Overview Video
Navigating to Notes
From the "Clients" section of your provider dashboard, select the client you'd like to view. This will take you to their Client Record Profile.
From the Client Record Profile, select "Notes" from the menu bar.
From the "Notes" section, you can review existing notes, create a new one, amend existing notes, or chat with our AI assistant about the client's history
Creating a Clinical Note
We've streamlined the process of generating a clinical note for your appointments. After selecting "New Note" within the Notes section of the Client Record, you'll be able to select between templates at the top, and either utilize AI assistance to draft your note, or type within the template independently.
Within the AI Input box, you can switch between typing and dictation as needed, and the AI assistant will organize your input into the template format after you select "generate."
After completing your draft (either with or without AI assistance), you can choose to "Save & Close" or "Save & Lock" your note.
"Save & Lock": The note will be locked, and further changes will need to be made through formal amendments. Notes in a locked state can be shared with your client.
"Save & Close": The note is available for further edits, but cannot yet be shared with your client.
Once you are satisfied with your note and it has been locked, you'll then be able to share it with your client.
Sharing Clinical Notes with Clients
After a note has been created and saved with "Save & Lock" you'll be able to share it with your client from within the note itself. Under the Note Details, there is a toggle for whether the note is "Held" Or "Shared" and visible to the client in their portal.
Viewing Existing Notes
You can review all existing notes for a given client from within their notes tab in the Client Record Profile. You'll see all notes, details on their status, and be able to click into them for further details.
When viewing one note, you'll also see a list of other notes for that client and be able to navigate to them as needed.
Amending a Locked Note
Once a note has been locked, any further edits must be made through "amendments". To make such an adjustment, simply select the note and click "Amend" at the top right.
You'll be prompted to input a reason for the change, and then can make edits freely before selecting "Save Amendment" at the top right. Completing this process will save a record of the amendment in the history of the note.
Clinical Notes - Ask AI
Within the Notes section of the Client Record Profile is a helpful AI assistant that can reference all prior clinical notes for the client being viewed. You can ask it things like:
What has the chief complaint been the last few appointments?
What medications is this patient on currently? Have they mentioned trying any others previously?
This tool exists to save you time sifting through notes by populating the information you need, when you need it.