Notes can be added to a care plan by using either of the following text fields:
Patient Care Plan Notes - Use this field to communicate information regarding the care of the patient. Information is shared with the patient (and other providers) on Visit Summary Reports and Continuity of Care Documents (CCDs). This field can be used for anything that does not fit into a goal (such as "Patient walks with a cane" or "Receives Meals on Wheels").
Provider notes - Use this field to document internal notes that are not shared with either the patient or other providers. A provider may wish to enter significant information that can affect patient care but that is sensitive (such as "Patient denies having a problem with alcohol consumption/alcoholism").
Note: These two fields are shared by all providers. Any provider can edit any other provider's entry. You may wish to identify your entry with your initials or clinic name.
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. You can also add custom paragraphs as appropriate. For details, click here.