Clinical Documentation
A signed note is the legal record: it is never edited, only addended.
Where to find it
Address in the console: /ehr/notes
List · 8 columns · 12 fields on its form · 2 of them required · 2 actions
What the list shows
These are the columns of the list, in the order they are drawn. Any of them can be sorted on, filtered on, hidden, or exported.
| Column | Kind | Field name |
|---|---|---|
| Note | Code | note_no |
| Patient | Text | patient_name |
| Type | Status | note_type |
| Author | Text | author_name |
| Department | Text | department_name |
| Written | Date and time | created_at |
| Signed | Date and time | signed_at |
| Status | Status | status |
The form
What is asked for when a record is created here. Required fields are marked; a choice drawn from a configuration list is one an administrator can extend without a release.
| Field | Type | Choices | Notes |
|---|---|---|---|
| Patient required | Choice | Looked up from existing records | |
| Encounter | Choice | Looked up from existing records | |
| Department | Choice | Looked up from existing records | |
| Author | Choice | Looked up from existing records | |
| Template | Choice | Looked up from existing records | |
| Type required | Choice | Configuration list | |
| Subjective | Long text | ||
| Objective | Long text | ||
| Assessment | Long text | ||
| Plan | Long text | ||
| Free text | Long text | ||
| Requires cosignature | Yes or no |
What you can do here
Sign primary
Asks for confirmation: Sign this note? Once signed it can only be addended, never edited.
Asks for: Signing provider
Addendum
Add to a signed note
Asks for: Addendum* Author
* required
The rules that apply here
Everything on this screen obeys the platform rules rather than rules of its own. The ones worth knowing before you use it:
- Narrowing a list — search, conditions, sort, totals, export and saved views.
- What may be changed — the five grounds a record may not be edited on.
- Companies and business units — what the switcher above this list is doing to it.
- Creating a record — required fields, where choices come from, and how the number is allocated.
- Importing a spreadsheet — this screen accepts one, and it runs through the same rules as typing.