Quick Guide to Ten Hints About Notes - 1.6

Transcription

1 Quick Guide to Ten Hints about Notes Ten hints about notes: 1. Notes are written documentation within the patient chart. 2. Notes can be written by any member of the health care team. 3. Notes will be marked as signed, using their username, by the person currently logged into the EHR, unless otherwise noted. 4. Notes will be stamped with the current date and time unless otherwise noted. Change the author or time here. The note will also record the actual author and time. 5. There are two basic types of notes: Templated and Untemplated. a. Templated notes will bring up a template in a new window and users can complete the documentation by filling out the template. Choose Finish when done and the recorded documentation data will appear in the word processing window on the right side of the notes tab screen. You may add any additional free-text documentation to the narrative text on the right side of the notes tab screen after "finishing" the template. 1

2 Templated Note. Fill out the template by checking the box to open each section. Choose Finish when done to return to the word processing window. b. Untemplated notes will enable the author to write a free-text note in the word processing window on the right side of the notes tab screen. This is the word processing window where you can add free-text charting and where you create Untemplated note content. Right-click in this area to sign a note, edit a note, or create an addendum. 2

3 6. Unsigned notes are considered work in progress and will be automatically saved, even if the chart is closed. To complete an unsigned note, read the Quick Guide for Documenting in Templates. 7. To re-open an unfinished template, choose Edit Progress Note... then open the Action menu at the top of the screen and select Reload Boilerplate Text. Follow the steps provided in Quick Guide for Documenting in Templates. This will bring the template back. 8. To change note titles, click the Change button, located in the upper right-hand area, above the word processing window. 9. ***Unsigned notes will not be visible to anyone other than the author. Only signed notes will be visible to the rest of the health care team for reading (or the instructor). 10. To sign a note, right-click on the body of the note and select Sign Note Now or open the Action menu and choose Sign Note Now. You will also be prompted to sign a note when you refresh or exit the patient's chart--you may sign if the note is complete, or decline to sign it if you will need to finish the note later. **Optional settings You may want to change your personal options for saving notes, default co-signers, or adding subject headings to notes. Here s how: Open the Tools menu at the top of the screen and select Options (it s at the bottom of the list). In the Options box, click on the Notes tab. 3

4 a. In the Options box, select Notes and set your auto save default to 5 or 10 seconds. This means the EHR will automatically save your notes every so many seconds, in case you lose your internet connection or close the EHR. b. Check off the box next to Ask subject for progress notes to have your notes enable a secondary title. c. Students may want to select a default co-signer if they always send their notes to the same instructor. Now when you write a new note, you will have an additional Subject line, i.e. Subject Heading, for giving your note a more focused purpose. 4

5 Screen displays may vary among different sites and you may not see the data on your monitor exactly as shown in this manual. Although screens are subject to modification, the major menu options and workflow can be followed from this manual. Please contact support if you need assistance in following this manual. 5