Description

Total Care Progress Notes, also known as MHWS Total Care Progress Notes, is an essential tool integrated within the BOSSnet and Communicare clinical information systems. This feature is designed to enhance the documentation capabilities of clinical staff, allowing them to efficiently record, view, and edit progress notes for each patient service. By doing so, it ensures the continuity and completeness of clinical records, which is crucial for maintaining high-quality patient care.

Key Features

• Comprehensive Documentation: Tailored for Mental Health and Wellbeing Services, these notes become part of the official patient clinical record once completed and submitted.

• Accessibility: Users can add this feature to their favorites in BOSSnet for quick access. During system outages, hard copy forms are utilized and later integrated into the system to maintain documentation continuity.

• Historical Management: The Progress Notes tab provides a detailed view of historical services, organized by encounter and provider. It includes essential details such as date, time, place, provider name, specialty, and reason for the encounter. Users can adjust the level of detail displayed, from basic headers to full notes, and track any amendments made to the notes.

Editing and Permissions

• User Control: Users with appropriate permissions can edit current and previous service details, provided they were involved in the service. Access to notes can be restricted by tagging specific disciplines, ensuring that visibility aligns with user access rights.

• Filtering Options: Notes can be filtered by provider, encounter place, mode, or specialty, with the historical notes list refreshing every 60 seconds to capture updates.

Integration and Usability

• Clinical Information Integration: Progress notes can incorporate clinical items, medications, investigations, imaging, letters, and recalls, providing a comprehensive view of patient care.

• Spell Checking: An Australian English spell checker is included, highlighting errors as users type and offering manual checks.

• Recalls and Referrals: The interface displays a summary of recalls and referrals, with options to filter items due within the next year.

User Interface

• Navigation: Right-click menus offer convenient access to printing and editing options for both historical and current services, enhancing user interaction and efficiency.

Common Use Cases

• Clinical Encounters: Ideal for recording and updating patient progress during clinical encounters.

• Documentation Management: Facilitates the review of historical clinical notes and the management of documentation amendments, supporting multidisciplinary teams in accessing relevant clinical information.

By providing these robust features, Total Care Progress Notes significantly contributes to effective clinical documentation and information management within healthcare settings.