This user guide provides instructions for creating and documenting provider notes during procedure creation.
Understanding Terminologies
- Provider Notes
Provider notes are written observations, comments, or details recorded during a procedure to document important patient treatment information.
Add a Provider Note for a Procedure Through EMR Board
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Choose the Body Area from the dropdown menu and click “Start Procedure.”NoteFor services without a selected procedure type, you will be prompted to choose the procedure type at this step.
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You will be directed to the Procedure View Screen in the patient profile, where all procedure sections are displayed.
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To access “dot phrases,’’ type a dot (.) in notes. These pre-created phrases will appear in a dropdown menu, allowing you to quickly select and insert repetitive notes instead of typing them manually.
NoteTo use Dot Phrases, you must first create and save them in the Dot Phrases List within Clinical Documentation in the portal. Once saved, simply type a dot (.) to insert them. For step-by-step guidance, refer to the “Manage Dot Phrases” tutorial.
The provider note has been successfully added!
Add a Provider Note for a Procedure Through Patient List Screen
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The patient details will be automatically filled in. Complete the booking and procedure details, then click “Save & Chart” to proceed to image upload and access the Marking Screen.
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Enter the required information in the Provider Note field and click “Save” to confirm.
The provider note has been successfully added!
Add a Provider Note for a Procedure Through Bookings List Screen
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The patient and booking details will be automatically filled in. Complete the procedure details and click “Save & Chart” to proceed with uploading images and accessing the Marking Screen.
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On the Marking Screen, select the Provider Note tab at the top.
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Enter the required information in the Provider Note field and click “Save” to confirm.
The provider note has been successfully added!
Edit a Provider Note Through Procedure View Screen
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Make the necessary changes, then click “Save” to save the updates.
The provider note has been successfully edited!
You’re all set
That’s every step of “Add / Edit a Provider Note for a Procedure”. Up next: Add / Edit Booking Notes.