This document discusses how to define and create notes in an electronic medical records system. It describes linking a foundation file to establish note margins and locations, selecting a title, tab, and doctype for the note. It also discusses adding note elements like vitals, medications, and inserting default text that can apply to specific users or all users. The default text can include variables and its font size can be set globally.

1. Notes: Advanced
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2. Underlying RTF
 The underlying .rtf file used to compose
Notes should be located in a network
shared directory commonly named Notes.
Multiple .rtf files may be designed for use
in different Notes. Letterhead elements
may also be included in the .rtf Foundation
File.

3. Defining the Note
 When Defining a practice Note, a Title for the Note is selected. Headers
and Footers are created, and the Tab and DocType where the Note will be
filed, after completion, are selected
 The window for Defining a Note is opened by clicking Notes - Define Note
 Click Add
 Enter the desired name as the Note Title. The next step is to Link the
Foundation File. This Foundation File establishes the Note margins and the
locations of preprinted elements such as: patient name; date of service;
MRNumber; and date of birth. Click the open file folder icon (to the right of
the field) to browse to the desired .rtf
 You may use the Default or Edit the .rtf file. To Edit the underlying .rtf file,
please contact Support directly for a listing of fields that may be used and
for further instruction. If desired, you may select a letterhead graphic for the
Header, type the desired Header or leave blank. Again, if desired, you may
select a graphic for the Footer, type the text or leave blank. Next, select the
Tab and DocType from the drop down lists. If the practice has multiple
locations, you may select the appropriate location
 Please note that care should be taken to include the full path to a shared
network directory for Foundation .rtf files or Header and Footer graphics

4. Note Elements
 The Elements listed below are some of those included in eMedRec
for use in creating Notes. After defining and assigning Elements to
a Note template, Elements are then manipulated through the Active
Note Editor.
 Open Table - Text with no heading
 Vitals
 Medication
 Medical History
 Family History
 Social History
 History Present Illness - HPI
 Physical
 Review of Systems
 Impression
 Plan

5. Default Text
 Default Text may be inserted, automatically, in any of the Note
Elements
 Default Text that applies to all Notes from all Users is entered in the
Define Note Elements table by clicking Notes – Define Note
Elements
 Often the Default Text varies depending on the physician and the
type of Note
 Individual physicians may enter Default Text for the Elements of
their Defined Notes by clicking Notes – Element Defined Text.
 Select the User and the Note, then click on the Element and enter
the Default Text
 Variables may also be used in Default Text. Refer to Section 6.5.1
which deals with Default Text Variables. Save changes
 Font size for Default Text can be set by selecting Default Text Font
Size from the menu

6. Default Text
 Default Text may be inserted, automatically, in any of the Note
Elements
 Default Text that applies to all Notes from all Users is entered in the
Define Note Elements table by clicking Notes – Define Note
Elements
 Often the Default Text varies depending on the physician and the
type of Note
 Individual physicians may enter Default Text for the Elements of
their Defined Notes by clicking Notes – Element Defined Text.
 Select the User and the Note, then click on the Element and enter
the Default Text
 Variables may also be used in Default Text. Refer to Section 6.5.1
which deals with Default Text Variables. Save changes
 Font size for Default Text can be set by selecting Default Text Font
Size from the menu