Creating Notes

Creating notes in Healthland's structured documentation tool, Notes, is based on using templates and importing data elements, using filters.  The following topics are discussed on this page:

To create a note

Adding Patient Data while Creating a Note

To copy a note forward

To save the note as draft

To sign a note

To edit a note

To add an addendum to a note

To delete a note (Mark Erroneous)

About the Create Note pane

From the Create Note pane, you can toggle between two modes depending on which tasks you wish to perform. The toggle button is located next to the Filter View drop-down.

• The Create/Edit Mode is the displayed view when the panel is first opened and is used to enter note text and to select templates and data filters to be used in the note.

• Filter View Management Mode: The Filter View Management Mode allows users to create and edit the filter views and rearrange filter groups and filters.

Click on the toggle button to switch between modes.  

To create a note

1. From the Main dashboard, select the desired patient.
2. Then, click the Notes icon on the main dashboard to display the Notes window.
3. The Create Note panel displays by default. (To access using the sidebar menu, select Create Note.) [+]

   

4. Review and set the Date/time: The date and time for the note default to the current. Click in the date/time field to modify the date and/or time.
5. Select the Note Type: Select the type of note you are creating from the drop-down list next to the date/time field. You can set your default note type clicking the star icon in front of the note type.

Note Types are created and maintained in Maintenance > General > Note Types.

6. Select a Filter View: In the field at the top of the left side of the page, use the drop-down list to select a Filter View. The Filter View determines what filter options are displayed below the Filter View field in the left pane of the Create Note window. (Note: The default view is called Centriq Default View. This filter view is "canned" for all facilities, can be copied as a new filter view and customized, but the Centriq Default View cannot be edited or deleted.)

To create filter views, click the toggle button located next to the Filter View field. See To create Filter Views for instructions.

7. Select a template: Click on a template from the Templates section using the following methods:
   
• Templates that have been "favorited" are displayed in the Template section. Click the desired template to load it to the window.   See To favorite a template for additional details.
• Search for a template in the Template search box. Type the desired text you are looking for in the ...search across name and author field and press <Enter> or click the magnifying glass button. The results are displayed in a drop-down list.  (You can favorite templates by clicking the star icon.) Select the template by clicking it from the list. The template is loaded in the note text window.

8. Type Text in the Note: If not using templates, or if you wish to add additional details to the note, you can just begin typing in the Note text window.
   
9. Insert Images: To insert an image into the note, click the image icon in the tool bar. The Image box is displayed. You can choose to Upload a picture (most common) or insert via URL. Click the Choose File button and browse to locate and select the picture. Click OK to save and insert the picture.  Use the Advanced tab to modify the image width, height, and the space around the image. NOTE: At this time, if a discharge document contains an image and an ED Disposition is done, the images will not print from the unsaved Chart View. It is recommended to print the saved ED Disposition from the Patient Chart Reports.  

10. Insert Patient Data into the Note using Filters: Click in the note in the location that you'd like to add the patient data. Then, click the desired data filters listed on the left side of the window. The data filters are grouped by categories: Demographics, Problems, Allergies, Current Medications, Vital Signs, Surgical History, Labs, General, Chief Complaint, Home Medications, Family History, Social History, and Immunizations.
    
    As you click elements, the data populates the note. Use the following tips when using filters:
    

• Healthland provided filters are available for use and be found in the Filter Library or when using the default filter view: Centriq Default View.

• Ensure your cursor is where you want the data element to enter the note prior to clicking the item in the left hand column.

• If you hover over the data element name, the data is displayed in a hover box for viewing prior to clicking and inserting it into the note.

• You can customize the list of filters that are available to you using Filter Views. See To create Filter Views for details.

• Create a new filter by clicking the blue filter icon in the category header. See To create custom filters for additional information.

• Expand and collapse filter categories by using the arrow buttons located in the category header.

• You can customize the order of the filter list in the Filter View Management Mode.  While in Filter View Management Mode, move your favorite filters to the top, drag and drop the filters into the order you prefer.

• The Surgical History, Problems, and Chief Complaint data sets allow you to add, edit, and delete patient data from the panels. Look for the blue add button (plus). Click this button to add new patient data to the record - allowing it to be displayed in the current note. See Adding Patient Data while Creating a Note for additional details.

• Sometimes there is no available data to populate in the note. In that case, a statement indicating that no information is available is displayed the patient record.

• There is a filter category titled Medical Summary with two data elements: Assessment and Hospital Course. Both of these selection display a colored labeled box in the note. Insert your cursor in the colored box and enter the appropriate information to include it in the note. Note: These fields will eventually be pulled into the C-CDA in a future release.

• When using global filters  - filters that are available for all uses - they may get unpublished, deleted, or edited by the user who created it or an administrator. When this happens, you will see a red exclamation point icon displayed next to the filter. If you click this filter to use it, a message is displayed informing you of the changes, what the changes are, and who changed it. From the message, select the Update to New Formula, Remove from View, or Keep Old Formula. If you select Update to New Formula, you will insert the data filter using the newly edited filter. If you select Remove from View, the filter will be removed. If you select Keep Old Formula, it will let you keep the old formula but require that you rename it.

11. Make any other edits to the note using the text formatting tools, e.g. font, size, underlining, etc.
    Tip: There is a threshold alert icon in the lower left corner of the note window that indicates the file size of the note being created/edited. The icon will change color (from light gray to dark gray to black to red) to indicate the size of the note. When notes are extremely large, it could impair system performance or slowdowns.
    
12. Click Sign. The note is displayed in the Note List. (You can also save the note as a draft. See To save the note as draft for details.)

Tutorial: How to Create a Note
To view the tutorial, click the Play button on the viewer below. Use the Full Screen/Exit Full Screen button to expand the viewer to full screen.




 For a list of all tutorials, see Notes Tutorials.

Adding Patient Data while Creating a Note

Some categories allow you to enter, edit, and delete patient data while you are creating the note. This allows you to add the data to the patient record, but not navigate away from the panes. The following sections allow you to add, edit, and delete patient data: Problems, Surgical History, and Chief Complaint. Look for the blue add button (plus) located in the header for the category.

1. Click the blue add (plus) icon. The List window is displayed with the current patient data listed in the grid. You can edit or remove existing items using the Edit (pencil) button or the Remove (X) button located next to the item.

The List grids are customizable - just like the Note List grid - by clicking the Configure Grid button located at the top right corner of the grid. You can change the sort order, make fields visible/not visible, rename columns, and group filters together using the options available. See To configure the Note List grid for details on configuring grids. Click outside of the Configure Grid window to close it.

2. Click the Add ... button located on the right to display the detail window. This will either be Add Problem or Add Surgery depending on the list you are viewing. [The Chief Complaint window is slightly different. It lists the current chief complaint entries along with date/time. Enter the new information in the text box and click Save.]
3. Enter the Problem or Surgical History item details.
4. Click Save and Add More or Save and Close.

To copy a note forward

Sometimes it makes sense to copy a note from earlier in the visit or from another visit to the current visit and modify a few of the details.

1. Go to Notes List. The  Notes List is displayed.
2. From the list, click the note you wish to copy. The note is displayed in the note text area.

Remember, to view previous visit notes, you must check the All Visits option to display them in the Note List grid.

3. Click Copy Forward. The Create Note window is displayed with a copy of the selected note in the text area.
4. Make modifications to the note using text entry, formatting tools, and data filters. See To create a note for details.
5. Click Sign.

To save the note as draft

Once you have completed the note, click the Draft button. The note is displayed in the Note List for the Created By user. You can discard a Draft note by clicking to view it in the Note List, then clicking Discard.

A draft note is not a part of the patient record until it is signed. It belongs to the author/user. The author/user is the only user that can edit their own draft note. Draft displays in the Signed date/time column for draft notes. Non-author users can only see that a draft exists but they cannot open it to read the contents.

Draft Notes can also be accessed from the Provider Work Center (for the Created By user) in the Draft Notes section.

To sign a note

Once you have completed the note, click the Sign button. To sign a Draft note, it is located in the Note List. Click on the note to display it. Then, click the Sign button.

To edit a note

1. Go to Notes List. The  Notes List is displayed.
2. From the list, click the note you wish to edit. The note is displayed in the note text area.
3. Click Edit Note. The Edit Note window is displayed.
4. In the Reason field, use the drop-down list to select a reason.  
5. Make modifications to the note using text entry, formatting tools, and imported data elements.
6. Click Re-Sign.

Tutorial: How to Edit a Note
To view the tutorial, click the Play button on the viewer below. Use the Full Screen/Exit Full Screen button to expand the viewer to full screen.




 For a list of all tutorials, see Notes Tutorials.

To add an addendum to a note

You can add an addendum to a note.

1. Go to Notes List. The  Notes List is displayed.
2. From the list, click the note you wish to add an addendum. The note is displayed in the note text area.
3. Click Add Addendum. The Add Addendum screen is displayed with the original note displayed below and the addendum box above.
4. Enter the addendum for the note in the text box using the formatting tools and data elements.  
5. Click Sign Addendum.

Tutorial: How to Add an Addendum
To view the tutorial, click the Play button on the viewer below. Use the Full Screen/Exit Full Screen button to expand the viewer to full screen.




 For a list of all tutorials, see Notes Tutorials.

To delete a note (Mark Erroneous)

You can delete a note from the Notes List.

1. Go to Notes List. The  Notes List is displayed.
2. From the list, click the note you wish to delete. The note is displayed in the note text area.
3. Click Mark Erroneous. (Note: The Mark Erroneous reason box is displayed. If the note is a draft note, the Discard button is displayed instead of the Mark Erroneous button.)
4. From the drop-down list, select a reason for removing this note. If you select Other, enter the reason in the Other Reason text field.
5. Click Mark Erroneous. The note is removed from the Notes List, however, can be viewed from the Notes List when the Erroneous option is checked.

Tutorial: How to Mark a Note Erroneous
To view the tutorial, click the Play button on the viewer below. Use the Full Screen/Exit Full Screen button to expand the viewer to full screen.




 For a list of all tutorials, see Notes Tutorials.