Change an Existing Note (Pediatric)

Use these steps to make changes to Preliminary or Draft status notes.

1.   If you haven't already, go to the Notes or Document Management module, and click the subject of the note to display it.

Note: Document Management defaults to displaying your Preliminary queue. If necessary, click Draft at the top of the screen.

2.   If necessary, update the service date.

3.   To update the subject of the note, use the Subject field.

4.   Change text by clicking the underlined section heading (on the right) to display the entry form for that section. Then, add or type over text.  To change entries (such as medications, allergies, and problems), click either the item name (to edit extended text) or the (to edit the associated entry form).

5.   To delete entries (such as medications, allergies, and problems), click the item from the list on the left, and click Delete. Doing so only removes the item from your note, not from the patient's record.

6.   To add information, follow the same steps as for creating notes (see Adding Visit Notes).

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

8.   If you reviewing the note of a resident, add an Attending Addendum, if appropriate.

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

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.

Related Topics

Adding an Addendum

Adding and Reordering Sections

Adding Information Using the Pt. Data Tab

Adding Patient Data Using System Macros

Amending Final Status Notes

Erroring Out a Note

Deleting a Draft Note

Setting the Default Notes Header

Signing and Saving for a Provider

Working with Distribution Lists for Notes (CC Lists)

Working with Placeholders