The Progress Note tab on the Consultation Screen lets you enter a clinical progress note without leaving the outcome workflow. The note is saved simultaneously with the appointment outcome and formally linked to the appointment, it is then viewable from both the saved outcome screen and the client's Progress Notes screen.
đNote: A progress note is not mandatory. If you do not need to record one, you can save the Consultation Screen without completing the Progress Note tab.
Record a progress note
Click the Progress Note tab.
Result: The progress note entry area is displayed. If you see a prompt instead of the entry area, you have no progress note types allocated to your account, contact your System Administrator.The Originator field is pre-populated with your name. If you are entering a note on behalf of another clinician, click the Search button next to the Originator field and search for the required user.
The Date and Time field is pre-populated with the current date and time (if configured by your organisation). Update this if you are backdating the note.
Select the Specialty (if required by your organisation) and the Note Type from the pick list. If a default note type is set for your user type, it will be pre-selected.
Select the Referral to which this note relates (if required).
Enter the clinical note text in the free text area.
Select any additional options as required:
Validate this note - validates the note immediately on save. Only available if you have Validate Own permission for this note type.
This is a significant event - marks the entry as a significant event and adds it to the Significant Events screen.
This note contains third party information - marks the note as containing information about a third party.
Add to Risk History - adds the note to the risk history. Select the appropriate risk types from the Not Selected list and move them to the Selected list.
To link the progress note to a care plan problem, select the checkbox next to the appropriate problem from the Current Problem Types panel. Only active care plan problems are displayed.
Do not save yet, switch to the Assessments tab if you need to record an assessment, or proceed to save the Consultation Screen.
â ď¸Important: Do not click Save until you have completed all tabs you need. The progress note and appointment outcome are saved together when you click Save on the Consultation Screen.
Record a note on behalf of another clinician
You can record a progress note on behalf of another clinician. For example, if a colleague saw the patient but cannot access Rio themselves.
On the Progress Note tab, click the Search button next to the Originator field.
Search for and select the clinician on whose behalf you are recording the note.
Result: The selected clinician is listed as the originator. The Specialty and Note Type pick lists update to show note types valid for the listed originator.Complete the progress note as normal.
Save the Consultation Screen as normal.
â ď¸Important: When recording on behalf of another clinician, you cannot validate the note. Only the originator can validate it after confirming that the content is correct.
Validation rules
Validation rules on the Consultation Screen are the same as on the standalone Progress Notes screen:
If you entered the note yourself, you can validate it immediately on save, tick the Validate this note checkbox before saving. This is only available if you have Validate Own permission for the note type.
If the note was entered on behalf of another clinician, only the originator can validate it after confirming the content is correct.
If you have Validate Others permission, you can validate another person's notes, but only if that person does not have permission to validate their own notes.
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