Adding Visit Notes (Free-Form)

1. If you haven't already, go to the Notes module.

2. Click Add New (or if you have a default template selected, select Free Form Text from the Add New Using Template drop-down list).

3. If necessary, update the following fields: Service date, Subject, Category, and Type. Or update additional notes classification options.

4. Click the main window and type the body of your note.

5. To add information from other areas of the patient’s chart such as medications or problems using the Pt. Data tab, see Related Topics.

6. To apply special formatting (such as bold or italic text) or check spelling, click the appropriate button. You must first select text when formatting existing text. If you have problems viewing formatted notes, click here.

7. If desired, click MRN (to add patient details) or Sig (to add a signature line) for printed notes.

8. At any time, click to save your work. You should do this periodically to prevent losing any data. Each time you click this icon, the information in your note is automatically saved to your unsigned data queue. You can also click Cancel (ALT+C) to exit without saving.

9. To save the note, click either Draft, Prelim, or Final. Or, save the note as a template.

10. Depending on your settings and patient data, additional prompts may display. For details, click here.

11. If you want to save your work now, click Sign (F10). The LMR indicates the changes that will be saved. Type your key and click Sign.