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 

1. From the Documentation section of the chart, click the Add Note button.
2. 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.
3. From the drop down type box, select the correct folder type.  
4. 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).
5. Type note in the upper panel of the Add Documentation window.
6. When the note is complete, click the Sign  button.