Patient journal entries

Overview

The patient's journal automatically updates when activity is performed on the file. In the patient's Journal tab, users can view existing journal entries or add new journal entries for charting, correspondence, follow-up purposes, etc. Each journal entry will denote the time and type of activity performed, the name of the user who performed the activity, and any additional text. 

Entering patient journal entries

1. On the Patient browser tab, open the patient’s file. 

2. Click the Journal tab.
3. On the Journal tab, click the NEW ENTRY button.
4. In the Patient journal entry dialog box, use the drop-down menu to select a journal entry type. 

5. In the text box, enter the desired notes.

6. Text Snippets are available on the right-hand side of the journal entries

   1. Drag and drop the snippet into the journal or start typing the auto-replace text to enter the snippet into the journal entry.

      

      Use the font and color options at the top of the Patient journal entry dialog box to customize the entry.

      For information on creating text snippets click here. Text snippets are also used for medical report writing.

7. Click SAVE.

The Display in audiology setting

Journal entry types, configurable from the Setup > Journal entry types menu, will each have the Display in audiology setting enabled or disabled. The Display in audiology setting for individual journal entries, of all types, can be modified from the Patient journal entry dialog box. The setting is available to modify when you are creating or editing a journal entry.

Editing patient journal entries

1. On the Patient browser tab, open the patient’s file. 

2. Click the Journal tab.
3. On the Journal tab, click on the journal entry you wish to edit.
4. Click the EDIT ENTRY button.

5. In the text box, adjust the content as necessary.

6. Click SAVE.

Deleting patient journal entries

1. On the Patient browser tab, open the patient's file.
2. Click on the Journal tab.
3. On the Journal tab, click on the journal entry you wish to delete.
4. Click the DELETE ENTRY.
5. In the Confirm operation dialog box, click YES.

Printing patient journal entries

1. On the Patient browser tab, open the patient’s file. 

2. Click the Journal tab.

3. On the Journal tab, click on one or more journal entries for printing.

   To select multiple journal entries use the Ctrl or Shift key when clicking on the list. Alternatively, you can select a range of entries by clicking and dragging the mouse pointer through the list.

4. Click the PRINT ENTRY button.
5. A summary of the selected journal entries will populate in a new Patient Journal Entries tab. Optionally, do one of the following:
   1. Click the ARCHIVE AS PDF button to archive the report under the patient Documents tab.

      • Within the Add document dialog box, input a Title, select a Category, and optionally add an additional Description and Status.

      • Click Save.

   2. Click the Save icon in the top left-hand corner to save the summary to your computer.
   3. Click the Print icon in the top left-hand corner to print the summary.

Signing patient journal entries

1. On the Patient browser tab, open the patient’s file. 

2. Click the Journal tab.

3. On the Journal tab, click on one or more journal entries for printing.

   To select multiple journal entries use the Ctrl or Shift key when clicking on the list. Alternatively, you can select a range of entries by clicking and dragging the mouse pointer through the list.

4. Click the PRINT ENTRY button.
5. Select the signer from the 'Signed by' drop-down menu.

You can read more about uploading user signatures here.

Alternatively, you can use your signature pad to electronically sign the journal entry. Read more about signature pad compatibility with Blueprint OMS here.

Filtering patient journal entries

1. On the Patient browser tab, open the patient’s file. 

2. Click the Journal tab.
3. Filtering options included are the following:

• Un-select Users you wish to exclude or click the Exclude all button
• Un-select Entry Types you wish to exclude or click the Exclude all button
• Uncheck the show appointments checkbox if you wish to hide patient appointments. 
• Check the Show inactive users checkbox if you wish to include inactive users
• Check the Show inactive entry types checkbox if you wish to include inactive entry types

 Searching for patient journal entries

1. On the Patient browser tab, open the patient’s file. 

2. Click the Journal tab.

3. Click on a journal entry and begin typing all or part of the desired text search string. The search will jump to the first matching entry. 

4. Use the up and down arrow keys to navigate through the list of matches.