Professional Notes
Professional Notes for Your Residents
The Professional Notes feature within Care Vision is great for adding notes generated by medical professionals such as doctors, dieticians, therapists, etc. It keeps all residents’ history and health records in one place, in digital form.
Carers can easily retrieve and view notes to get an update on residents’ health and wellbeing to help inform treatment going forward.
Attach Documents and Audio Files Easily
Professionals can upload documents and audio files related resident’s health concerns to the professional notes feature. If a medical professional doesn’t have time to write a detailed note, you can help them attach audio files to support their observations.
Select Notes for Multiple Residents
Another great sub-feature of Care Vision is the ability to select notes for multiple residents at once. Professionals can quickly and easily attach documents and audios for multiple residents in one go.
It can really assist professionals to save time and avoid having to enter data for residents individually.
Key Benefits
Assists in attaining higher levels of regulatory compliance.
Update carers quickly with residents’ health and medical status.
Helps carers decide how to improve residents’ health.
Enable professionals to send notes for multiple residents at once.
Frequently Asked Questions
Notes for medical purposes must be clear, accurate and concise. To help achieve this, some advice includes thinking about the facts, rather than opinions or suggestions. Use fewer words to get to the point quicker and keep phrases clear and understandable.
When your start writing notes, here are some requirements:
- Be clear
- Be concise
- Consider risk factors
- Be accurate
- Collect all the right information
- Make changes if needed
Most healthcare sectors use the SOAP (Subjective, Objective, Assessment and Plan) note format, which is probably the most common type of notes. It produces clear, comprehensive notes that follow a recognised format and doesn’t leave room for ambiguity or doubt.
Yes. Clinical paperwork such as SOAP notes and other forms can be considered to be part of a person’s legal medical records.