Progress Notes
Introduction
The Progress Notes and Laboratory Testing sections are designed to put important active patient info at your fingertips. Progress Notes are used to record any and all types of interaction and communication with your IP/patient and any progress with their individual care.
Writing a Progress Note
To write a Progress Note, click the page icon.
You have the option of creating free form text in the Notes section, or you may use stock text, by clicking the plus sign icon [1], dictation is also possible here by clicking the microphone [2].
If using the free-form typing Notes, type what you wish and then click Save.
If you choose to use stock text and click the plus sign [1], you will be able to compose new stock text by clicking Add Stock Text.
From here, add a Subject for the Stock Text and then enter your content and click Save.
To use your Stock Text, click:
[1] the arrow in the circle next to your selection, and then
[2] make any changes or additions to the text, when you are ready to save click
[3] Add to save your work.
You will then click Save on the following page and then enter your digital signature to time, date and user stamp the record.
Note: Often times you may be interrupted in the midst of writing a note. Simply click Save; then click Edit to finish your note when you have time. You have up to 36 hours to edit your note before it is finally committed to the database.
Laboratory Testing
In the Laboratory Testing section, you may record lab tests for your patient/IP and partner. To add a new Lab Test result, click the add test icon [1].
Fill in the Date, use the pull down menu to select a test name from a list of common tests ordered by your office, and enter the result. If you have a result with a value (not a positive or negative result) select Other, and you will have an additional window to enter the value. Select Female Patient or Partner and click Commit and Exit if you are done, or Next Result if you have more to enter.
