This article is for clinicians and medical secretaries who want to learn how to add, edit, and delete consultation notes for appointments. For information on how to print and share consultation notes, see here.
In this article:
Create consultation notes
You can create consultation notes for a patient at any time:
1. Go to the Patients page.
2. Select the patient who you want to create a set of consultation notes for.
3. Go to the Consultations tab.
4. Click New.
5. Select the type of consultation that these notes will refer to, and the date that the consultation took place.
6. Choose whether you want to use a configured template for your notes. Select Free notes if you do not want to use a template.
7. Fill out the consultation notes as you want. If you are doing Free notes, you can click the tags at the bottom to add another section to your notes. If you need to remove a section, you can click Delete record.
8. Choose whether you want each section to show in the patient's summary page.
9. Click Save at the bottom of the page.
The consultation notes appear in the patient's Consultations tab. Information from the consultation notes will also appear in the patient's Summary tab if you selected Show in summary for any of the sections that you filled out.
To enable this checkbox to be automatically selected instead, kindly go to your "medical settings" tab and check the box framed below:
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N.B. When you create consultation notes for a patient, Semble automatically saves a draft while you work.
If you lose connection, accidentally close Semble, or click away while creating consultation notes, you can find the saved draft by clicking New in the patient's Consultations tab. The saved draft appears, and is marked with an Unsaved changes tag:
Note: Drafts will only appear for the user who was writing them, on the device that they were writing on and within the same browser. If for example, you are working on one device, lose connection and then login to Semble on another device then you will not see these unsaved changes, or if another logs in and tries to access your notes this will not appear.
Edit consultation notes
Note: Before you attempt to edit consultation notes, you must first make sure that your practice has consultation note editing enabled. For more information, see here.
You can edit consultation notes from the Patients page:
1. Select the patient who you want to edit.
2. Go to the Consultations tab.
3. Click the drop down arrow next to the consultation that you want to edit.
4. Select Edit.
5. Make the changes you want.
6. Click Save at the bottom of the page.
Delete consultation notes
Note: Your clinic must have consultation note editing enabled from your clinic's Medical settings. For more information, see here.
You can delete consultation notes from the Patients page:
1. Select the patient who you want to edit.
2. Go to the Consultations tab.
3. Click the drop down arrow next to the consultation that you want to delete.
4. Select Delete.
5. Click Delete to confirm.
The consultation note is deleted from the patient's record.