General Note

Version 14.8

About General Note

Path: Smart Toolbar > Chart button > General Notes tab > + button

The General Note window allows Providers to enter any additional information about their patient.  The Note may be a general note, a historical note, or a review of systems (ROS) note. 

General Note Map

Number

SectionDescription

1

Section radio buttonsThe Section radio buttons select the type of note to be created.  Note selections are General, History, or ROS note.

2

NoteIn the Note text field you can enter your note.  The Phrase Construction icon opens the Phrase Construction window so you can create your note using pre-defined phrases.

3

VisibilityThe Visibility dropdown determines who is able to view the note.

4

Save and Cancel buttonsThe Save and Cancel buttons saves or cancels the note.

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Chart Review Tab (shown in History or ROS notes)The Chart Review Grid lists the date, progress note, primary diagnosis, and provider for the selected patient note.

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Audit Trail tab (shown in History or ROS notes)The Audit Trail tab indicates the staff name, date, time, and reason for the note creation.  It also lists the before and after change information.