The platform provides a streamlined approach to documenting patient information. Providers can create, manage, and finalize notes using customizable templates or system-generated content. Additionally, detailed transcripts are available for system-generated notes, ensuring accurate and comprehensive patient records.
Creating a New Note
Navigate to the Patient’s Profile
From the Patients tab, select the relevant patient.
Open the Chart Section
Click the Chart tab in the patient’s profile to access existing notes.
Initiate a New Note
Click the + New Note button.
Choose a Template or Start Blank
Select a predefined template (e.g., SOAP) for structured documentation.
Choose Empty for a blank note to input freeform content.
Fill in Note Details
Complete all relevant sections, such as Subjective, Objective, Assessment, and Plan.
Include any additional observations or recommendations.
Save or Finalize the Note
Click Save for Later to save as a draft.
Use Sign Off to finalize and lock the note.
Managing System-Generated Notes
Accessing System-Generated Notes
These notes are automatically created for appointments.
They include structured fields and transcripts of the session.
Viewing Transcripts
Select the system-generated note in the Chart section.
Navigate to the Transcript tab to review the recorded session details.
Editing System-Generated Notes
Update any fields in the structured sections based on insights from the transcript.
Note: Transcripts are not editable to maintain session integrity.
Signing Off System-Generated Notes
Verify structured fields for completeness.
Add billing details such as CPT codes if applicable.
Confirm declarations to finalize the note.
Editing and Deleting Notes
Editing Notes
Locate the note in the Chart tab.
Use the More Options menu (three dots) to select Edit Chart.
Update fields as needed and save or finalize the changes.
Deleting Notes
Locate the note in the Chart tab.
Use the More Options menu (three dots) to select Delete Chart.
Confirm deletion. Note that deleted notes cannot be recovered.
Best Practices
Review Before Signing Off
Ensure all information in the note, including transcripts, is accurate before finalizing.Leverage Templates
Use structured templates like SOAP for consistency and efficiency.Handle Deletions with Care
Only delete notes when absolutely necessary, as this action is irreversible.
FAQs
Can I edit a signed-off note?
No, signed-off notes are locked. You can create an addendum to address updates.What if the transcript has errors?
Transcripts cannot be edited. Use the structured sections to clarify or summarize details.Are transcripts included in all notes?
Transcripts are only available for system-generated notes based on appointments.