Entering a Note in the Medical Records

Within ClinicYou, notes are arranged in reverse chronological order in the medical records. Once you enter the notes, you will be able to undertake further actions on it (such as attaching a file / image to it, print or delete the note and of course, edit or refine it with AI).

To get to the medical records, there are several methods. The quickest will be to search for the patient - on selecting the patient's name, you will be taken to their patient's medical records. Alternatively, you can get there from the patient's demographics page by clicking the folder icon, clicking a task or notification item.

The EMR page lists the key actions you can take at the top of the page. The far right of this list is a plus icon, and this is what you click to start entering a note. In the resultant pop-up, there are different ways of capturing text (see below). Once you save the note, you can take further actions on it. The first three of these are in the vertical list of icons on the left. Click the grey triangle to open additional actions.

If there are no previous entries in the medical records, your + icon will be on the page itself so that you don't miss it. The popup to enter notes have a few things worth noting:

1. Context: Within ClinicYou, each note needs a context (e.g Outpatient Review, Operation Notes, Telephone Conversation etc). These can be anything you want and you can add a new one by clicking the + icon next to the dropdown. It is a good idea to carefully consider what you enter there.
2. **Canned Text: **this is where you can use re-usable blocks of text for quick data entry (e.g structured operation notes with headings). Of course you don't have to use this if that does not fit your workflow.
3. **Real-time voice to text: **This is a browser based integration and is useful for a quick note. Accuracy can vary
4. Text field: You can type your note here or use any of your favourite voice to text app - like Siri.
5. **AI based Automated Notes: **This can do a lot of your heavy lifting in medical documentation
6. **Recall: **You need to specify a recall item (e.g when you want to see the patient again) before you can save a note. The clinic and the patient will be notified ahead of the recall date (usually a couple of weeks before), so that appropriate action can be taken.
7. On the fly Invoice Item creation: If you have set up appointment types in the scheduler, these will appear here so that you can quickly capture an invoice items even if you did not give the patient a formal appointment.

Updated on: 28/09/2025