Clinical Notes
Clinical Notes are free text fields to track in qualitative terms the concerns of the specimen you are treating. In addition, there is an Animal Care Staff Medical Summary note - these details will be shared in the Animal Husbandry notes screens in ZIMS.
Topics:
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There are two formats for Clinical Notes:
- SOAP Entry – Subjective, Objective, Assessment and Plan
- Notes/Examinations/Report Entry
- Animal Care Summary (visible on husbandry side of ZIMS)
- Batch Entry
- Mark as Significant
- Mark as Private
- Active Problems
- Associated Tabs (Samples, Phys Measurements, Calendar Tasks)
- Other Actions
- Existing Notes for Same Day
- Note Templates
- Cloning Clinical Notes
- Searching Clinical Notes
SOAP Entry Notes
Using the SOAP entry format helps to standardize medical evaluations.
- S=Subjective - Your interpretations of what the patient is trying to tell. This can also be the reported history from a keeper
- O=Objective - Symptoms that can be measured, seen, heard, felt or smelled such as temperature, pulse, and swelling
- A=Assessment - Summary and medical interpretation of the significant Subjective and Objective observations and findings. May include diagnosis or preliminary diagnosis of the condition presented.
- P=Plan - How you intend to treat the animal.
This SOAP note will display only within the Medical ZIMS module.
Below is an example of a SOAP Clinical Note entry.
Notes/Examinations/Report Entry Notes
These notes are not broken down into separate topics like the SOAP entry and would usually be used for shorter notes. For this type of note you will need to select a Note Type.
If you create a SOAP entry and decide to switch to this type of Note you will receive a message that you cannot easily switch back to a SOAP entry.
Below is how the previous SOAP entry looks when converted to a Notes/Examinations/Report Entry note.
This note will display only within the ZIMS Medical module.
Animal Care Staff Medical Summary
The Animal Care Staff Medical Summary allows notes that are directed more at the animal husbandry staff than the medical staff. These entries will display in the Husbandry notes for the animal. They are not searched when Clinical Notes are searched.
Entry into Medical module:
Display in Husbandry record:
These notes cannot be edited or deleted from the Husbandry module and can only be edited or deleted from the Medical record.
Batch Notes
To help save time you can choose to enter Batch Clinical Notes for multiple animals. There are a few ways to select the records that you want to record multile notes into.
- Check the Batch Clinical Notes box and type the Local IDs or GANS into the field.
- Use an Animal List.
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Use the advanced search:
- Batch Clinical Note
- Search Glass
- Refine by enclosure/taxonomy ect.
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Select all relevant records
(click once, then shift + right click to select a range) - Select to add search results to the clinical batch note
- From Animal Search results grid (in Husbandry). Select the animals > Actions for selected animals > Make a simple batch action for selected animals.
When using the first two methods, the Note will be identical in all records. When creating a Simple Batch Note from a results grid you have the option to select a custom note. This means that the Notes recorded in each record can be different.
If you want to include a list of records the Note went into in each record, select the Include Local IDs in Note checkboxes as appropriate. The Local IDs will appear at the top of the Note. For a SOAP entry they will display only in the Subjective grid. It is recommended that you add your Note text in front of this Note so that the text will display first in the Details column of the Notes grid.
Mark as Significant
1) You can also choose to mark a Note as significant by checking the “Mark as Significant” checkbox.
2) Notes marked as significant will display with a red “!” icon so they are easily located in the grid. Marking a note as significant is similar to marking an email as High Importance. It is not something you should use often but is an indicator that this note contains something of significance.
Mark as Private
Checking the “Mark as Private” checkbox means that, even if you decide to share other Clinical Notes on the animal with another institution, this Note will not be shared. It does not mean that the Note is private to the person who entered it. It does mean that it is private to your institution and if other staff members have access to view Clinical Notes they will see it.
Active Problems
When you add a new Note all Active Problems are associated with that Note by default. However, there can be active problems such as old chronic issues where the current note is not relevant. If the problems are not associated with the Note, simply uncheck them. This Note relates only to the lenticular sclerosis and mild trauma. You cannot associate a note with a problem that is Inactive on the date of the note. If you want to create a new diagnosis You can select the “Create New Clinical Diagnosis” button and you will be taken to that screen.
Other Tabs Activate
If you select Save & Edit, the remaining tabs become active where you can record Samples, Physiological Measurements or create Calendar Tasks. If you select Save & Close, the Note will be saved and the data entry screen closed. The next time you open the Note record the other tabs will be active.
Additional Actions
Export to PDF, Edit or Delete the Note, highlight the appropriate Note in the grid as above. Then select the action you wish to take above the viewing pane as below. You can also open the edit screen by left clicking on the Note in the dashboard.
Existing Notes for Same Day
If you have already recorded a note in the animal record and you select to add another one for the same date, you will receive a screen displaying any other Notes that you recorded today for that animal. You can select to “Continue to add/edit context note” and you will be taken to the Add Clinical Note screen. Or, you can select to edit that highlighted Note. This helps guard against duplicated Note entries.
Note Templates
Note Templates help to make sure that you gather all the information you want on a specific topic. Note Templates can be created and managed from within the Animal Husbandry animal record or the Medical animal record. If you have Note Templates created already they will appear in the drop down list to select and use. If you wish to create a new one, simply type the information into the Note box and select the Save icon. To manage the templates, select the wheel icon. Because you created the Template from within Clinical Notes, it will by default be a Clinical Note Template.
Note Templates can also be created and managed from the Start Menu > Tools > Manage Note Template. The grid will display the type of template (left column), whether it can be edited by others and if it can be used by others.
Below we are creating a new Note Template for an animal’s first exam after birth or hatch. The Name should be unique. You will need to select the Template Type from the dropdown list. This template will ONLY be available for the type of note selected. This template will be shared with others, that means other staff members can use it. However, it is not editable by any other staff members other than its creator. In the Template Text record what information you want to collect in this type of note. HINT: when creating lists such as this example, use Shift/Enter to avoid extra spacing between the lines.
Cloning Clinical Notes
You can clone Clinical Notes to easily enter similar information. Both SOAP and Notes/Examination/Report Entry type notes can be cloned. You can also clone clinical notes for a single animal, group, or batch clinical notes.
To clone a note, select the desired note (1), then click the Clone button (2).
The cloned note will copy everything from the selected Clinical Note, except for the animal ID. This needs to be re-entered, you can choose to enter just one ID or use the batch function to assign the Clinical Note to multiple entries. You can now make any edits you need before saving as usual.
Searching Clinical Notes
1) Selecting Clinical Notes from the lower left panel will bring up the Simple Search for Clinical Notes.
2) Selecting Advanced Search …..
3) will add the fields to search by Problem or Taxonomy
Revised 5 March 2025
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