This article contains the following sections:
Adding Notes during Vaccine Administration
Viewing & Adding Notes any time before/after the clinical encounter
Purpose of ImmsBC Notes
- Please author a Note if the user intends for the information to be easily visible during future client visits.
- Examples
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- Parent requests a specific product for their child (e.g. 12 year old receiving the pediatric dose intended for 5-11 years)
- Explaining the rationale for an early dose
- Documenting clinical conversations around immunization history, reactions, recommendations, etc.
- Documenting tips or strategies for a needle-phobic individual
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- Please author a Comment if the information only pertains to the current clinic visit and may not be applicable for future encounters.
Adding Notes during Vaccine Administration (In-Clinic Experience)
To create a new note, click Add Note in the left hand sidebar. Users may use the Notes feature to provide details & clarification for other clinicians and clerical staff who may be reviewing the record.
Viewing and Adding Notes at any time
Previous Notes can be accessed under the Related Tab in the client's profile. New Notes can also be added at any time before/after the clinical encounter.
1. Click on the Related tab within the client's Person Account
2. Navigate down to the ImmsBC Notes section. Individual Notes can be expanded by clicking the Note ID (red arrow). Older entries can be viewed by scrolling within the Notes section.
3. Additional Notes can be added by selecting New.
4. In the large pop-up window, complete the following fields:
a. Confirm the identity of the client
b. Confirm the author's information
- By default, it is assumed that the user is writing their own note. If so, none of the settings need to be altered.
- If the user is transcribing a note on behalf of another provider, select ImmsBC Provider (User) and search for the individual by typing their name into the box.
c. In the next section, complete the following fields:
- Select the Note Type from the dropdown menu
- Immunizers may select ImmsBC Provider
- Clerical and data remediation staff may select Clerical
- Subject Line - short description/summary
- Note Text - free-text character limit of 3500
Editing a Note
1. Under the Related tab of the client's Person Account, scroll down to the ImmsBC Notes section.
2. Click on the Note ID that you wish to modify.
3. Click on the pencil icon next to the field(s) to be changed. Transcription details, Date/Time, Note Type, Subject Line, and Note Text can be edited.
Tips:
- Only the original author or users with ImmsBC Admin privileges have the ability to edit/modify a Note.
- The edit history for each note is recorded; the original text will be saved for reference.