Adding Visit Notes (Pediatric)

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

2. Click the at the Add New using Template field and click to select the template you want to use for the note. A list of sections associated with that note displays on the left.

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

4. Enter information by clicking a section name on the left. Continue as follows:

For all sections (except those linked to other modules in the patient's chart)

Fill out the entry form on the right as applicable. Use the following buttons to add comprehensive detail information with a minimum of typing:

- Adds either the practice-defined standard text comment, or the "normal" value for the associated subsection.

- Allows you to "carry forward" (or copy) a previous entry for a subsection. By default, the LMR includes the most recent entry; you cannot carry forward older entries.
For list-based sections (i.e. Problems, Medications, Allergies, etc.)
For EOV
For Vital Signs
For Results

5. 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.

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

7. To save the note, click either Draft, Prelim, or Final.

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

9. 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.