Enhanced Clinical Documentation: Unveiling Clinical Notes

Streamline patient encounter documentation with the new Notes with Macros feature.

In our commitment to alleviate clinical burden and elevate patient care, we are thrilled to unveil our new Clinical Notes feature - a giant leap, with many more to follow. This feature is designed to enhance your patient documentation experience, making it more structured, efficient, and enriching.

Notes with Macros

As you embark on a patient encounter, the feature presents a dedicated text field, paving the way for detailed and organized documentation. Formatting tools are at your disposal to emphasize text, structure your notes, and ensure clarity, making your documentation journey smooth and enjoyable.

The hallmark of our Clinical Notes lies in its dynamic functionalities. The feature houses Macros, a powerful tool that speeds up the documentation process while adding depth. Begin with the / shortcut to embed pre-configured text snippets curated by you or your peers. This is especially invaluable for note templates or frequently used phrases.

Variables are another noteworthy aspect. Use the $ shortcut to insert predefined data from the patient chart such as $patientAge or $patientFullName, making the documentation more personalized and accurate.

Moreover, the feature introduces Note Blockers to ensure no crucial information is  missed before signing off the notes. Type {{!}} on your macros wherever you want some information to be added and the note blocker prevents you from signing the note before you review and remove it.

Example of a Variable

Scenario Snapshot: Hypertension Documentation

Let's explore this with an example: imagine you're in an encounter with a patient who has high blood pressure. By simply typing /, you can trigger a macro for a standard hypertension encounter note. This macro populates a template with SOAP sections, including a Note Blocker at the Objective section to remind you to input the physical examination results. This feature not only speeds up the documentation process but also ensures a thorough note is crafted without overlooking crucial details.

This note template can also encompass common text elements shared with other templates, such as your signature or a header. These elements can utilize variables to auto-fill the patient's name and date of birth.

When it's time to finalize your note, the template's blocker prevents signing until you've recorded the vital measurements. Once you remove the blocker and input the measurements into the patient's chart, they will be automatically integrated into the note. With a final signature, your documentation is complete and ready!

At SigmaMD, we're all about making things better. Our new auto-save feature and detailed logging of changes after signing show our effort to keep your work safe and clear. This is just the start. We're working hard to improve the Clinical Notes interface to make documenting easier and help improve patient care. With each note, we're one step closer to exceptional patient care, and we're excited about the updates we have planned.

Stay tuned for more features that will help make your practice more efficient and focused on patients.

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