Quick Guide to Ten Hints about Notes
Ten hints about notes:
1. Notes are written documentation within the patient chart.
2. Notes can be written by any member of the health care team.
3. Notes will be marked as signed, using their username, by the person currently logged into the EHR,
unless otherwise noted.
4. Notes will be stamped with the current date and time unless otherwise noted.
Change the author or time here. The note
will also record the actual author and time.
5. There are two basic types of notes: Templated and Untemplated.
a. Templated notes will bring up a template in a new window and users can complete the
documentation by filling out the template. Choose Finish when done and the recorded
documentation data will appear in the word processing window on the right side of the notes
tab screen. You may add any additional free-text documentation to the narrative text on the
right side of the notes tab screen after "finishing" the template.
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Templated Note. Fill out the template by checking
the box to open each section. Choose Finish when
done to return to the word processing window.
b. Untemplated notes will enable the author to write a free-text note in the word processing
window on the right side of the notes tab screen.
This is the word processing window where you can add free-text
charting and where you create Untemplated note content. Right-click
in this area to sign a note, edit a note, or create an addendum.
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6. Unsigned notes are considered work in progress and will be automatically saved, even if the chart is
closed. To complete an unsigned note, read the Quick Guide for Documenting in Templates.
7. To re-open an unfinished template, choose Edit Progress Note... then open the Action menu at the
top of the screen and select Reload Boilerplate Text. Follow the steps provided in Quick Guide for
Documenting in Templates.
This will bring the template
back.
8. To change note titles, click the Change button, located in the upper right-hand area, above the word
processing window.
9. ***Unsigned notes will not be visible to anyone other than the author. Only signed notes will be
visible to the rest of the health care team for reading (or the instructor).
10. To sign a note, right-click on the body of the note and select Sign Note Now or open the Action
menu and choose Sign Note Now. You will also be prompted to sign a note when you refresh or exit
the patient's chart--you may sign if the note is complete, or decline to sign it if you will need to finish
the note later.
**Optional settings
You may want to change your personal options for saving notes, default co-signers, or adding subject
headings to notes. Here’s how:
Open the Tools menu at the top of the screen and select Options… (it’s at the bottom of the list).
In the Options box, click on the Notes tab.
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a. In the Options box, select Notes… and set your auto save default to 5 or 10 seconds. This means
the EHR will automatically save your notes every so many seconds, in case you lose your
internet connection or close the EHR.
b. Check off the box next to Ask subject for progress notes to have your notes enable a secondary
title.
c. Students may want to select a default co-signer if they always send their notes to the same
instructor.
Now when you write a new note, you will have an additional Subject line, i.e. Subject Heading, for giving
your note a more focused purpose.
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Screen displays may vary among different sites and you may not see the data on your monitor exactly as
shown in this manual. Although screens are subject to modification, the major menu options and
workflow can be followed from this manual. Please contact support if you need assistance in following
this manual.
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