Lesson 5 MD Rounding Documentation And Filing Charges Flashcards
New note
Creates note with free text or SmartTools
Changing view of problem list
Configure view under the option button Modify columns that appear and act on them- resolved, deleted, non-hospital and multidisciplinary problems Can be sorted by priority and class List view Show Choose columns Share with patients
Note writer
Documents pt progress and current condition using point and click functionality
Prebuilt templates
Document findings system creates notes
Process for documenting in NoteWriter
Click create in NoteWriter
In Select note type & template window choose appropriate note type
Select template most applicable
Click accept
Basic structure of NoteWriter
Forms r located on the Tabs on top
Note window on bottom
Side bar report to the right
Summary side bar where u can select other reports found to the far right
NoteWriter macro
A predefined set of values that can be pulled into a note with a click of a button
How to create a macro
From current documentation
Select create macro from current data found top toolbar arrow down I between the person and snapshot
In new window give the macro a name
Click accept
The SmartBlock Macro Editor appears where u can modify and document anything u want to save for that note
Make modifications
Confirm checkbox next to active is checked to make available for use
When documenting with a positive/negative button how can u quickly indicate that a specific condition is ab sent or negative
Right click
When documenting with a positive/negative button how can u quickly add a comment
Hover over and type
How can you tell if a comment has already been added to a positive/negative button
It is underlined
Is free text allowed
Yes you can add additional information to your note by using SmartPhrases or free text in the white space within the note
