Classic medical note usage

Estimated reading: 4 minutes

Learn how to add a classic medical note to a patient record and add an addendum to a finalized medical note. Classic medical notes are the previous version of medical notes used in Cornerstone 7.6 and earlier versions. If you are new to the IDEXX Cornerstone Practice Management System, or new to using medical notes in Cornerstone, we recommend using the enhanced medical notes format.

Before you start

Security

Important!

  • Classic medical notes cannot be edited, once they are finalized. You can add an addendum to it.

Add a classic medical note to a patient

Navigate by doing one of the following:

  • Patient Clipboard > right-click on a patient > Medical notes > All medical notes
  • Toolbar > Medical Notes
  1. Enter the Client ID, Patient ID and Staff ID, using Tab to move from one field to the next.
    Note: Depending on how you access the Start New Document window, the Client ID/Patient ID fields may already be completed for you.
  2. In the Category drop-down list, select Classic medical note.
    • Use the additional search fields in the Find Template area to locate the desired template.
    • To see a preview of a template, click on the template in the list. A preview displays below.
  3. Once you have located the desired template, select it and click OK or double-click on the template.
  4. Click Data Entry, if any data fields are set up in the template. Enter the required information and click Tab after each entry.
  5. Click Spell Check to review for spelling errors.
  6. Click OK to return to the Medical Notes window.
  7. If you want to immediately finalize the Classic medical note upon saving, click Final.
    • Classic medical notes with a status of Final cannot be changed.
    • To finalize the notes automatically at a later date, click Auto finalize after check and enter the appropriate number of days.
  8. To attach a file or a URL to the medical note, under Attachments, right-click and select New File or New URL, as needed.
    • If you select New URL, your default web browser will open.
    • Locate the web page you want to attach and copy the address.
    • Return to Cornerstone, right-click under Attachments, and select Paste URL.
  9. Click OK to save your changes.
    • If your classic medical note has invoice items or consult items on it, and you did not finalize it, a message will display prompting you to transfer items to the Patient Visit List.
      • Click Yes to transfer items to the Patient Visit List
      • Click No if you do not want to transfer items at this time.
    • Note: See Additional information for more information on consult items.

Add an addendum to a finalized classic medical note

Addendums insert additional notes at the bottom of a finalized Classic medical note, after they have been finalized. This adds an Addendum section to the end of the document that includes:

  • The additional notes
  • Date and time
  • Staff member who added the addendum

Navigate to one of the following:

  • Patient Clipboard > Medical Notes tab
  • Patient Clipboard > Summary tab
  1. Double-click on the medical note to open it.
  2. Click Addendum.
  3. Type the Staff ID, press Tab and type the addendum text. Click OK.
  4. The addendum is added to the Classic medical note.

Additional information

General

Related reports

  • Radiology (Imaging) Log
  • Surgery/Anesthesia Log
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Classic medical note usage

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