Go to the 'Clients' tab within the case management software
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Find your client and click on their name 🧑
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Select ‘Client Record’ 👇 below their name
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Hover over the blue ‘Create’ button on the right-hand side, this should open a drop-down menu, you can select 'Note' 👇 here
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You can then select a template if you do want to select one, please note that you can edit and add new templates by pressing manage templates
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Then fill in the Title and additional details of the Note✍️, in this case below, I’m using the risk assessment template
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Once you have completed the note you can scroll down and see a menu of options
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Select the date and time 👇, you can select dates in the past as well
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You can mark this as a key event ⭐, key events will be shown on the summary page of the client (Imagine it as pinning a post on Facebook)
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You can assign it to another colleague e.g. if they are away and you need to add a note on their behalf
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You can also upload a file by pressing the files button ☁️
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You can choose to send it back to the patient’s medical record, if you are, select the appropriate GP practice to send it back to (Please note files are not sent back)
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If you are sending this information back to the clinical record, select the relevant SNOMED codes
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Use the scroll wheel to go to the top and select the ‘Save’ or ‘Save and Send’ ✅ button
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Congratulations, you have added a Client Note to Joy! 🎉