Adding Notes/Add'l Info to a Patient's Chart

Version 14.19
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Notes/Addl Info

About

The Notes/Addl Info section of the Patient Chart is used to set default Visit Types for the patient (for example if they required extended visit times), set their employment and marital status, maintain Miscellaneous and Billing Notes, and document who referred the patient to the Practice. Edits made in the window will prompt the user to save their changes when they attempt to navigate away from the window. Below you'll find further information on how to populate:

Default Visit Types

The default Visit Types selected in the Default well visit type and Default sick visit type fields are used to indicate that the patient requires additional time than what is normally scheduled for visits. Selecting an option from these drop-downs alerts the scheduling staff when an appointment is being scheduled so that the defaults are honored during scheduling. Selections should only be made here when it is appropriate to do so. Otherwise, these fields should remain blank. To remove a selection previously made, highlight the selection and press Backspace on your keyboard to clear out the field.

Employment and Marital Status

The Employed/Student and Marital status options are used when it is necessary to document this information. By default, Part-time/not employed and Single are selected.

Miscellaneous Notes

Miscellaneous Notes are used to add comments or other information to a patient's record without interfering with their medical chart data. Typically, Miscellaneous Notes are specific to No Shows or other general information. While Miscellaneous Notes can be entered in the Notes/Addl Info section of the Patient Chart, they can also be viewed, added, edited, and removed in the Clinical Overview section of the Patient Chart and in the Add/Edit Appointment window.

Patient Chart > Clinical Overview
Users can use the arrows on their keyboards to move through additional notes. To view all notes or make edits, double-click in the field to open the Notes and Coordination of Care window (shown in the last image below).
Calendar Schedule > Open Appointment
Users can use the up and down arrows to move through additional notes. To view all notes or make edits, click the ellipsis button to open the Notes and Coordination of Care window (shown in the last image below).
Notes and Coordination of Care window
Edits made to the Miscellaneous Notes in this window update the Notes everywhere they are displayed.

Billing Notes

Billing Notes are generally used to document the patient's financial standing with the Practice, such as if they owe a balance or if a Coordination of Benefits is needed for outstanding claims to be processed. While Billing Notes can be entered in the Notes/Addl Info section of the Patient Chart, they can also be viewed, added, edited, and removed in the Add/Edit Appointment window and in the Billing Panel of the Tracking window.

Calendar Schedule > Open Appointment
Users can use the up and down arrows to move through additional notes. To view all notes or make edits, click the ellipsis button to open the Notes and Coordination of Care window (shown in the last image below).

Tracking Schedule > Billing Panel
Users can use the arrows on their keyboards to move through additional notes. To view all notes or make edits, double-click in the field to open the Notes and Coordination of Care window (shown in the last image below).
Patient Info/Notes and Coordination of Care window
Edits made to the Billing Notes in this window update the Notes everywhere they are displayed.

Referred to Practice

If your Practice keeps track of who refers a patient to the Practice, that information can be entered in the Referred to practice by field. The Add button opens the Address Book where the user can select the referring provider.