Electronic Documentation – Clinical Notes Using the Clinical Note for Documenting: Consults, H&Ps, Discharge Summaries, Progress Notes, Cardiology Notes and Operative Notes Click your arrow buttons if you wish to advance from slide to slide.
Adding Documentation 1. Open the Patient’s chart. 1 You can document a Consult, Discharge Summary, H&P, Progress Note, Cardiology Note or an Operative Note by opening the Reports tab in the patient’s chart and selecting the type of documentation you wish to complete. 2. Click on Reports tab.
Adding Documentation continued 2 3. Click on the Add Document icon.
Adding Documentation continued 3 4. Click the Type of document (e.g. Consult, Discharge Summary, H&P, Progress Note, Cardiology Note or an Operative Note ).
Saving versus Signing a Document You may save an entry to complete at a later time. If you have completed your entry, you may sign it now and it will be saved as a Final Report . Some types of documents such as H&P include a template for you to follow. 4 6. Type or paste your patient information into document. (Do not paste content from a PDF, TIF, GIF or MPEG file.) 5. Complete the Subject line. For example: H&P, Daily Progress. Etc. 7. Click “ Save ” if document is incomplete or “ Sign ” if the document is complete. <ul><li>To copy text from another application: </li></ul><ul><li>Highlight the text, right click, select Copy or press and hold the CTRL key then press the c. </li></ul><ul><li>In your Clin Note, click in the note. press and hold the CTRL key then press the v or click the Clip Board Icon to paste. </li></ul>
Saving Displays as “Preliminary Report” You may save an entry to complete at a later time. If you have not completed your entry, you may save it as a Preliminary Report . The document content can be modified when it has been saved rather than signed. 5 The document will display “ Preliminary Report ” at the top of the page if is saved and not signed as complete. Saved documents are only visible to the author and are not yet part of the medical record.
Signing Displays as “Final Report” You may modify a signed or saved document. The document can be modified once it has been signed, but modifications will show as an Addendum . The original content of a signed document cannot be changed. 6 The document will display “ Final Report ” at the top of the page once it has been signed by the physician. It will display as Preliminary until signed if document is forwarded for completion and/or co-signature.
Locating a Saved or Signed Report 1. Open the Patient’s chart. 7 You may review a Preliminary Report or a Final Report by locating it in the patient’s chart. 4. Click the button to sort your documents on this patient by type, status, date, performed by, or encounter. 5. Click the arrow to move up and down to the next selection. 2. Click on Reports tab. 3. View the signed document shown with a red box meaning Authenticated (Verified) or the saved document shown with a pink box meaning “In Progress” in left-hand column. ( See Status Color codes in the chart below.)
Modifying a Document 2 . Right click inside the document to open the menu. 8 Once you locate the document in the patient’s chart, you may modify it. 3. Click Modify Document . 1. Double click the document you wish to modify.
Modifying a Saved Document 9 4. Type or paste additional patient information into document. (Do not paste content from a PDF, TIF, GIF or MPEG file.) 5. Click “ Sign ” if document is complete.
Viewing a Final Report 10 The document will display “ Final Report ” at the top of the page once it has been signed .
Modifying a Signed Report The document can be modified after it has been signed, but modifications will show as an Addendum . The original content cannot be changed. 11 1 . Type or paste additional patient information into a signed document as an Addendum . (Do not paste content from a PDF, TIF, GIF or MPEG file.) 2. Click “ Sign ” if document is complete.
Viewing an Addendum on a Signed report 12 The document will display: “ Final Report Document Contains Addendum ” at the top of the page once it has been signed .
Forwarding a Note or H&P for Completion &/or Signature 13 You may be required to forward a note for endorsement or co-sign. 1. Right click inside the note. 2. Select Forward/ Refuse .
Selecting Physician to Co-Sign 3. Select Physician who will sign. 4. Click “For Signature .” 5. Click OK . 14
Electronically Proxying to Physician The document will display: “ Electronically signed on…” and “Electronically proxied on…” Proxying sends the note to the designated physician’s inbox for signature to become final. 15
Co-signing a Note The Physician will right click on the first note in the series. When the Physician opens his/her Inbox, the notes requiring signature will appear as “Pending” 16