Monday, October 18, 2010

LSS Hints: Changing Document Type

If you have started a document for an encounter, and wish to change the document type to another format, you need to create a new document, carry over vital sign information from the old document, and then cancel the first document.  This cannot be done if the document is signed, and both documents must be associated with the same encounter.

In the appropriate patient chart, select the Document tab button to open up the document functionality.  If the old document appears, then click on the Enter New footer button to create a new document.  This document will be associated with the current encounter.

Select the appropriate template type.  When the document opens up, the medications and allergies will be automatically entered from the EMR.  Open up the nursing portion of the document by clicking on the Nurse Note toggle button.

Click on the Vitals field.  The vitals from the previous note will be filled in.  Click OK or OK & Next as appropriate.  Fill in the information as you normally would.  Click on the Save As In Process footer button.

The document list will reappear.  Click on the incorrect document to open it up.  Click on the Edit/Amend button.  This will open the document.  Save the document by clicking on the Save footer button.  This should bring up the sign menu.  Click on Canceled and enter the reason for canceling when prompted to do so, and then save again by pressing the Save footer button.

If the incorrect document was signed, then call IT to get the document converted back to unsigned status.  A signed document cannot be canceled.  Then go back and cancel the document as above.

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