Classic medical note setup

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.

Classic medical note defaults

To include only certain comments/fields from a Classic medical note in correspondence, select Display partial medical note in correspondence in Documents defaults.

With this option selected, the Include in corres field displays on the right side in the Classic Medical Note Templates Field Setup dialog box.

Classic medical note templates

Types of information you might enter in the templates include routine information, such as temperature, lab results, or a SOAP.

Set up a template

Navigate to Lists > Documents > Templates.

1. Click New to display a menu of template options. Select Classic medical note template.
   
2. Type a description for the template.
3. Select Auto-finalize, If you want this template to be automatically finalized during end of day processing.
   • Enter the number of days after which this template will be marked as final.
4. Click Field Setup (or press F6) to add the template fields, if needed.
   • Fields will be automatically filled with information when the template is used.
   • See Classic medical notes template fields for details.
5. Enter any additional text you would like to appear in the template, such as headings for the fields.
6. Click Spell Check to review your template for spelling errors.
7. Click OK to save your changes.

Update a template

Navigate to Lists > Documents > Templates.

1. In the Category drop-down list, select *Classic medical note, to narrow your search to only classic medical notes.
2. Select the classic medical note in the template list and click Update, or double-click on the template.
3. Change any of the following, as needed.
   • Description
   • Auto finalize and number of days
   • Add, update or delete fields
     
     Notes:
     • See Classic medical notes template fields for details.
     • Note: If you are updating and existing template a template field cannot be deleted, if it is already used in patient history.
   • Change field headings
4. Click Spell Check to review your template for spelling errors.
5. Click OK to save your changes.

Classic medical note template fields

Data fields can be added to have information automatically populate when the medical note is used, and for data entry.

Tip: Place manually entered data fields at the top of the template. Place the fields which have defaulted values at the bottom of the template. When you complete data entry, you will not have to tab through all the defaulted fields to manually enter data. 

Set up template fields

1. Set up your classic medical note template.
2. On the Classic Template Setup dialog box, place the cursor in the desired position within the Template area.
   • This is where the information from the first field will display when the template is used.
   • Click Field Setup or press F6.
3. In the Entry Name drop-down list, select a data entry field name to specify the type of information to use on the template line. The corresponding Field Type is automatically selected based on the Entry Name.
   
   Note: The entry names or field types selected during field setup do not display or print on the medical note.
4. Select a Default Item ID.
   Note: This option is available for the invoice item or diagnosis type fields.
5. Enter a value in Default Value, if needed, and press Tab.
   • Using default values saves you from entering the same information over and over again.
6. Enter a description of the information you require, in the Entry Description field. Example: Enter Subjective.
7. Select Include in corres for each field you want to include in correspondence. Note: This option will only be displayed if Display partial medical note in correspondence is checked in Documents defaults.
   
8. Click Add, to add another field.
   • To delete a field, click within the line and then click Delete.
     Note: If you are updating and existing template a template field cannot be deleted, if it is already used in patient history.
9. Click Spell Check to review for spelling errors.
10. To move a field up or down in the template, click the field’s entry name and click the up or down arrows.
11. When finished, click OK to close the Field Setup dialog box.
12. Type a heading in front of the field name in the Template area, if needed.
    
13. Continue with the template layout and content entry in the Template area. Click Field Setup, as needed, to insert fields throughout the template.

Additional information

Related reports

• Radiology (Imaging) Log
• Surgery/Anesthesia Log