EHR1 Podiatry Note Editor User Guide Version Old Stockyard Road, Suite A Marshall, VA

Transcription

1 When starting PNE (Podiatry Note Editor), the Open Encounter Note window will automatically appear. This will display previously created notes. This dialog is also used to search for notes, using the patient information fields at the top. The fields at the top can be used to narrow down your choice of patient when you would otherwise have a lot of notes to look through. The Patient ID field is useful when integrating with an EMR.

2 Creating a New Note If you would like to create a new note, click Cancel at the bottom of the window to progress directly to the editor. 1. The buttons along the top can be used to open new notes, save the current note, or to sign the current note. Only one note can be open at a time. 2. This section allows you to enter a name for the doctor. The doctor name will display on the note, so listing the full name and credentials (ie. Thomas M. Smith, MD) is recommended. 3. The doctor ID is used for file naming when integrating with an EMR. Work with EHR1 Support regarding EMR Integration. 4. This is the location of the Current Complaint and Present Illness fields. These fields are required in order to sign a note. The arrow in the upper left of the outline section can be used to hide/show the field.

3 Adding a Diagnosis Among the buttons on the options tool bar at the top of the window is the Add Diagnosis button. Selecting this button will open the Visual Diagnosis Navigation Screen. This is the Visual Diagnosis Navigation Screen. This interface will help select a diagnosis in just a few clicks. In the Podiatry note editor, all selections above the knee are disabled.

4 After selecting a body part, a list of diagnoses will appear. Skin, Bone, Muscle, Joint, and Nerve can be selected to hone in on a specific diagnosis. On the next page, Muscle has been selected, and the diagnosis listing has updated.

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6 Selecting a diagnosis will input it into the encounter note, as shown below. From here, the note can be edited freely. Additional diagnoses can be added by selecting the Add Diagnosis button again. Additional diagnoses will append to the previous diagnosis. Edit accordingly for duplicate exam findings.

7 Changing Note Defaults If you would like to change the note associated with a diagnosis, you can use Save as Default Note to set the current note as the baseline for every subsequent selection of that diagnosis. The Save as Default Note feature allows you to customize your note collection with personalized content, saving time when creating future notes. The more customized default notes you save, the more time you save!

8 When you have completed a note, you can sign it using the Save and Sign Note button. There are a number of options available when saving and signing a note. 1. The Doctor Name and ID will appear, and can be altered here. 2. The type of encounter can be selected. 3. A secondary location can be chosen to save a copy of your signed note. The signed note will also exist in your EHR1 Data directory. This field is commonly used with/for EMR integration. 4. You may opt to open the note after it has been saved & signed. 5. Click Sign to save and sign the note. 6. Preview un-signed note 7. Cancel, and return to the editor. Previewed un-signed notes and signed notes will open separately in Adobe. Un-signed notes will be watermarked.

9 In the Open Encounter Note window, signed notes will appear when you click on an encounter. You can choose View or Export to open or save these signed notes. Limiting your search to signed notes is useful here, as are the Name, Patient ID, and Visit Date fields. PNE version 1.4 adds an additional Sign All feature to the Open Encounter Note dialog window. Clicking Sign All will allow you to sign all notes currently displayed in the Open Encounter Note dialog.

10 This window differs slightly from the Save and Sign Note dialog. o The number of notes to be signed will display at the top of the window. o The note type can be overridden here for all selected notes. o Ordinarily, this dialog will skip notes that have already been signed. Check this box for those notes to be re-signed instead. You can contact EHR1 support to have the following changes made to the program: o Edit Header/Footer Information o Edit images of logos displayed in signed notes o Modify signed note naming convention for EMR integration o Modify or move the notes repository o Configure the application for network-based access or multi-user environments