Adding Visit Notes (Structured)

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.

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

4. Click the name of a section (or subsection) in the main note pane to activate it. Type text or import previously entered comments.

5. To add information from sections linked to the patient's chart, click the next to the section name in the main note pane. Continue as follows:

For list-based sections (i.e. Problems, Medications, Allergies, etc.)
For EOV
For Vital Signs

Note: To edit entries, click the next to the entry.

6. To add Results, click Results in the left pane.

7. To insert a custom paragraph, click to select the section, then click the custom paragraph drop-down list on the toolbar above the main note pane. Select the paragraph you want to insert.

8. 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.

9. 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.

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

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

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

13. 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.