Writing a Progress Note
This document describes how to type a note in the Documentation section.
When documenting, it is essential to make sure you have selected the correct patient and encounter, and that the correct folder type is selected.
Opening a new note
- From the Documentation section of the chart, click the Add Note button.
- The Add Document box will open. The Type, Date, and Subject fields must be completed.
NOTE: Type is the folder in which the completed note will display.
- From the drop down type box, select the correct folder type.
- If the correct note type is not displayed, expand the choices. Right-click in the Type box, select Document Type List and Complete to display the complete folder list. If unsure of the correct folder to select, contact HIM (Medical Records).
- Type note in the upper panel of the Add Documentation window.
- When the note is complete, click the Sign button.