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 typing over it. To change entries (such as medications, allergies, and problems), click the next to the entry.
5. To delete entries (such as medications, allergies, problems, and physical exam sections), click the at the far right of the section. 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. To save the note, click either Draft, Prelim, or Final. Or, save the note as a template.
9. Depending on your settings and patient data, additional prompts may display. For details, click here.
10. 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.
Adding and Reordering Sections
Adding Information Using the Pt. Data Tab
Adding Patient Data Using System Macros
Setting the Default Notes Header
Signing and Saving for a Provider