Patient Electronic Health Records

Elements and format of a patient's health record

Your patients' electronic health records form a part of their patient profile and ensure you can securely access patient records across your practice locations and in your home, irrespective of which computer system you use and without the need to maintain two HealthKit accounts for the one practitioner. You can also review a patient's clinical and health history, so you can ensure you provide treatment that is optimal to their needs.

Electronic health records encompass case notes, reports, referrals, social history and other clinical records. They also enable you to add images, and upload and attach files to case notes.

Clinical templates

Main articles: Preset clinical templates and creating your own templates and Selecting templates

Clinical templates for case notes, letters and clinical reports are either preset for you from HealthKit's template library based on your profession and the fee or referral that you select when making an appointment, or you can create case note, letter and clinical report templates yourself. You can create templates, add attachments or link templates to fees and reports on in the template section of your Settings page.

Accessing and viewing a patient's health record

Access clinical notes from - 1: your calendar and 2: a patient profile

Main articles: Elements of a patient health record, Patient's social history

A patient's health record includes their case notes, appointments, referrals, reports, assessments, social history, general notes and any other records associated with a patient's health. A patient's Clinical tab is structured so that you can see each element of their clinical record down the left-hand side in blue, with the current record that you are viewing in green, and attached files in grey.

You can access a patient's clinical record in two ways:

  1. From a patient's profile: go to the patient's profile from your Patients List, invoice or your calendar, then click the Clinical tab; and
  2. From your Calendar: When an appointment has been made with the patient on your calendar, click the appointment on the calendar, and click the Notes button.

Practitioners with the appropriate level of access can also click the Social History tab on a patient's profile to view and edit their demographic background and details.

Creating clinical notes, reports and letters

You can create and begin a patient's clinical note in two ways:

  • From your calendar: click on an appointment that has already been made, and click the Notes button to go to the clinical notes specific to that appointment; and
  • On their patient profile: click the Clinical page, then click the New Clinical Note button. This method is best used when there is no appointment associated with the clinical note. You can choose the type of record that you are creating.

You can then begin entering notes into the clinical note that you have created.

Clinical tools, tests and assessments

How to access HealthKit tools, tests and assessments
How to select HealthKit tools, tests and assessments

HealthKit includes a broad range of clinical tools, tests and assessments, including:

  • Mental health: such as K10, DASS21 and DASS42;
  • Physical therapy and disability: such as the Orebro Musculoskeletal Pain Questionnaire, and the WHODAS 2.0 (WHO Disability Assessment Schedule 2.0);
  • Medication management: including prescriptions; and
  • General tools: including the AUDIT alcohol screening tool;

as well as many other tools, tests and assessments that can be completed during appointments or shared with patients. All tools include the ability to input relevant patient information, as well as scoring where required.

You can access clinical tools by clicking the Templates button in the formatting bar, and then either:

  1. Selecting the tool from the list (which you can scroll through); or
  2. Typing the name of the tool in the search field and selecting the tool from the list.

After you click on the tool, the tool appears on the right of the screen. Click Save to add it to this clinical note. You can then complete the tool, or, if available and appropriate, share the tool with the patient.

You can develop your own clinical tools, and you can also link clinical tools, tests and assessments to fees and referrals, so that the clinical tool automatically appears for appointments covered by the fee or the referral.

Note: If using a template and clinical note together, it's important that you select your template first as adding a template will overwrite any notes that are entered.

Annotatable body charts

You can track treatment, patient pain and body assessments on annotatable body charts, which you can see in this video.

To access a body chart, click the Templates button and select the relevant body chart. When you click Save, the body chart is shown in your clinical notes. You can annotate the body chart in two ways:

  1. Drawing: draw on the chart with your mouse (this is the default option); or
  2. Text: which can use in the following way:
    1. Click the Text button,
    2. Drag the text box that appears to the relevant area of the body chart;
    3. Click in the text box;
    4. Type the words; and
    5. Click Save.

Your annotations appear on the body chart.

Click the New Clinical Note button to add detailed case notes about the body chart.

You can also share the body chart with your patients, and link the body chart to fees and referrals if the body chart is always required for a specific fee or referral.

Note: If using a template and clinical note together, it's important that you select your template first as adding a template will overwrite any notes that are entered.

Formatting patient records

Formatting patient records

Main article: Formatting patient records

Once you have created the required patient record (or once it has automatically been created for you), you can begin entering patient records, including case notes, letters, referrals, reports and assessments. Formatting your records is similar to formatting in Microsoft Word, and you can format text and paragraphs, move text, add tables and lines. You can also add images and dynamic terms, as well as select your preferred template. You can also change the size of your screen to maximise the editing space available.

Updating fees and invoices from patient records

Adding fees when writing patient records

You can add fees and edit invoice fee amounts while writing patient records. First click the down arrow next to the invoice number, then:

  • Changing the fee amount or details for this appointment: click the Edit icon next to the fee, and make the changes required;
  • Adding another fee to the invoice for this appointment: click the Add Fee button, then select the fee that you want to add to the invoice (or add the fee to your Fee List here if it is a new fee) and click Save.
  • Deleting a fee: click the delete icon next to the fee and confirm that you want to delete the fee.

Click the up arrow next to the invoice number to collapse the view.

Saving and publishing patient records

Saving, publishing and deleting patient records

All patient records including case notes, reports and letters are automatically saved as you type. You can also click the Save button at the top right. Once saved, the status of a patient record is recorded as Draft. If your internet goes down or becomes very slow, you receive a notification telling you to manually save the note by clicking the Save button because otherwise automatic saving may be affected.

Medical professional codes of ethics require practitioners to lock down their patient records once you have confirmed and finalised it. Publishing (i.e. locking down) a patient record makes it load faster because the text editor does not need to be loaded. You can publish (i.e. lock down) a patient record by clicking the small arrow to the right of the Save button and selecting Publish. Publishing converts dynamic text to the actual words - for example, [Patient given name] [Patient surname] becomes the patient's actual name (e.g. John Smith) when it is printed.

You have limited rights to revert a published patient record to Draft status. Click the Revert button (or the small arrow to the right of the Revert button) that appears at the top right of published patient record, and confirm that you want to revert the note to Draft status. Once reverted, you are able to make changes to the record.

Sharing a patient record and assigning tools

Sharing patient records

Where you deem it clinically appropriate, you can share a clinical note with:

  • Another practitioner in your group whose access level would otherwise not let them access the clinical note (e.g. if the practitioner has Personal Access and so can only see their own direct patients' records and not other practitioners' patients' records), which is particularly helpful when the practitioner must treat the patient unexpectedly; or
  • The patient themselves.

To share the clinical note, click the small arrow to the right of the Save or Revert button (if the note is in draft status, sharing the note converts the note to published status), and select whether you want to share it with the patient or another practitioner in your group. If you select that you want to share the clinical note with another practitioner in your group, select the practitioner's name from the Practitioner drop down menu. You can also select that you want to share not just this clinical note but the entire patient file with the practitioner.

After you click Save, the record is made available in either the other practitioner's HealthKit in their Patients List and the patient's profile, or in the patient's HealthKit patient portal.

When you have created a tool in HealthKit, you can assign the tool to a patient by clicking the Assign option under the Save button. The tool is assigned to the patient in their HealthKit patient portal for them to complete. When they have completed and saved the tool, it is shown in your list of clinical notes for that patient.

You can turn on or off the ability to share patient records and assign tools with patients on your Settings page (this feature is turned on by default).

Sending patient records securely

Sending secure messages

Patient records can be sent to other practitioners if both you and the receiving practitioner have an account set up with either Referralnet or Argus. If you have not set up an account yet, you can do this from your Settings page. In order to send notes through secure messaging, you first need to have an account set up with either Referralnet or Argus.

To send a message to another practitioner, click the triangle next to the Save button and click either SMD ReferralNet or SMD Argus.

You can use any of the search criteria to narrow down the search. Search for the practitioner to whom you are sending the note. This will look through the ReferralNet or Argus database. Click Search. Select the Recipient and click Next.

A summary appears on screen confirming the details being sent. Select the message type and click Send when ready.

Deleting a patient record

To delete a part of a patient's record (e.g. a case note, clinical report or letter), click the small arrow to the right of the Save button when a record is in Draft status. Select Delete from the drop-down menu and confirm that you want to delete the record. The record is then removed from the health record listings down the left hand side.

You can only delete patient records that you own, and you cannot delete a patient record if it has been published for longer than two weeks.

You can also delete a full patient profile on their General page; click here for more information.

Printing patient records

Printing patient records
Clinical note contents and template printing preferences

You can print either a single patient case note or all the patient's case notes. There are two ways to print clinical records:

  1. By clicking the print and print preview buttons at the top right of the screen, which prints a patient note using your connected printer on your letterhead; and
  2. By clicking the triangle next to the Save button and selecting print - this is also how you print all of the patient's case notes.

When printing, you can:

  1. Preview what records look like printed;
  2. Print records; and
  3. Set your preferences for the format of printed records.

Click the Preferences icon to set your content and template preferences for printing clinical notes. You can choose to print (a) just the contents of the clinical note; (b) the contents and appointment details or (c) the contents, appointment details and invoice details. You can also choose whether to include your header and footer on the note or not, or whether to include your header and footer on the first page only.

When you print a patient record, dynamic terms are automatically converted to actual words - e.g. [Patient given name] [Patient surname] becomes the patient's actual name (e.g. John Smith) when it is printed.

Watch this video to see how to do this.