TABLE OF CONTENTS

General comments

Form names should use standard format as per notes below.
Use an abbreviated name of the department, so that the full form name is visible in Cortex. e.g. ‘Gen Surg’ rather than ‘General Surgery’

Admission notes

Name these as [Department name] Admission
these are for the initial, usually more detailed assessment
Some departments may have multiple admission notes for RMOs and Registrars. In this case the form name should be ‘[Department name] [role name] Admission – e.g Ortho Reg Admission
Non-paediatric admission notes should have a panel at the top that uses an age-related conditional rule to appear if the patient is 15 years or younger. This informs the clinician they should consider using a paediatric admission form.

Name as [Department name] ward round note
As these are typically completed by an observer, they don’t control the order that information arrives. Therefore they need to quickly access and complete different questions. Hence, showing checkbox rather than lists allows much faster completion of information as all the options are visible and only one tap to complete.
Ensure that there is a ‘Round Lead’ box at top. Usually best to use a Token component with the User database
Ward rounds are critical points of information capture. Think about what the people who read the ward round notes need from the ward round. For example in a surgical ward round diet status is important. Documenting follow up is important for those being discharged. Therefore build these questions in and make it simple to provide the answer. Structured questions and prompts help people remember to ask.

Name as [Department name] progress note
Progress notes are used for many other clinical encounters that are not admissions or ward rounds. For example:
- ‘Check response to treatment’
- ‘Documentation of advice from another service’
- ‘Family concern / request
They should have a Rich Text advice at the top that they are not to be used for initial admission documentation or the main ward round of the day.
They should include a date / time picker to document when the patient was actually seen.

‘Consult’ notes are used when providing input to a patient who is under another team
For services which can also admit their own patients, these notes should be titled ‘[Service name] Consult to Another Service’ - e.g. ‘Gen Med Consult to Another Service’
- This is used for the initial assessment
- Subsequent patient reviews can be captured under usual ward round notes or progress notes.

For teams that do not admit their own patients (e.g. Palliative Care), these should be named as:
- [Service Name] Initial Consult - e.g. ‘Palliative Care Initial Consult’
- [Service Name] Progress Note
The ‘Consult to Another Service’ and ‘Initial Consult note’ types have a category in Cortex of ‘Consult Notes’ which is their filter category in the Cortex timeline
They should include a date / time picker to document when the patient was actually seen
These notes should have a Rich Text component at the top of the form (viewer only) stating ‘Further patient reviews by this service may be under Ward Round or Progress notes’