Electronic Documentation Clinical Notes

1
Electronic Documentation Clinical Notes

• Using the Clinical Note for Documenting
• Consults, HPs, Discharge Summaries,
• Progress Notes, Cardiology Notes
• and Operative Notes

Click your arrow buttons if you wish to advance
from slide to slide.
2
Adding Documentation
You can document a Consult, Discharge Summary,
HP, Progress Note, Cardiology Note or an
Operative Note by opening the Reports tab in the
patients chart and selecting the type of
documentation you wish to complete.
1. Open the Patients chart.
1
3
Adding Documentation continued
2
4
Adding Documentation continued
3
5
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 HP
include a template for you to follow.
4
6
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
7
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
8
Locating a Saved or Signed Report
You may review a Preliminary Report or a Final
Report by locating it in the patients chart.
1. Open the Patients chart.
7
9
Modifying a Document
Once you locate the document in the patients
chart, you may modify it.
2. Right click inside the document to open the
menu.
8
10
Modifying a Saved Document
9
11
Viewing a Final Report
10
12
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
13
Viewing an Addendum on a Signed report
12
14
Forwarding a Note or HP for Completion /or
Signature
You may be required to forward a note for
endorsement or co-sign.
13
15
Selecting Physician to Co-Sign
3. Select Physician who will sign. 4. Click For
Signature. 5. Click OK.
14
16
Electronically Proxying to Physician
The document will display Electronically signed
on and Electronically proxied on Proxying
sends the note to the designated physicians
inbox for signature to become final.
15
17
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
18
Opening a Note to Co-Sign
1. Click open.
17
19
Signing a Note
2. After reviewing note, click Sign. 3. Click OK
Next or OK.
18
20
Recognizing a Signed Note
19
21
Viewing a Notes Status
20
22
Verifying a Note Is Co-Signed