LSS Hints: Practice Notes

The Practice Notes sidebar button in LSS will display all the practice notes associated with the current patient.

Here are some highlights of this page:

• The initial listing is in reverse chronological order
• You can click on the blue-i icon or the Date field to open the most current note associated with that entry.
• A balloon in the Hx column indicates there is viewable text associated with the current line entry with a revision history.
• You can click on the balloon in the Hx column to open up the revision history of the document. 
• There may be one or more entries listed with different date and times.  You can click on a date and time entry on this screen to open the document associated with that revision.
• If a provider dictates note which  is then transcribed,  and then the provider signs the document, there will be at least two revisions, one for the transcribed document and one for the signed document.
• Any amendments to the document will result in a revision history entry.
• Clicking on many of the tan headers (Date, Type, Provider, Status, Reason) will sort the list based on entries in that column, usually alphabetically.

There are several types of documents listed on this page.

• Chart Notes - Notes not associated with an encounter, i.e. phone message, preentry of information, medication renewal, messages, etc.
• Phone calls to and from the patient regarding lab work, medication refills, etc.
• Preentry of data (although this may be entered as History for PFSH)
• Encounter - Notes associated with an encounter that do not have a dictated, transcribed, or typed entry by a provider, i.e. lab work, x-ray order, medication refill, vaccination, etc.  An encounter is almost always a scheduled visit by the patient, such as clinic visit, lab work or imaging.  However, it is possible to create an encounter without an actual patient visit)
• Clinic note  - Encounter associated with a dictated, transcribed, or typed entry by a provider
• History - Encounter associated with PFSH history, not associated with a dictated, transcribed or typed entry by provider
• Nurse office visit - Notes associated with an encounter that may have an entry created by nursing.

Sometimes medication refills are associated with an encounter and sometimes they are not.

The listed progress notes can have several different status options:

• Signed - Dictated, transcribed, or typed entry by a provider that has been signed by the provider.  This is an option available in the Status sign menu.
• Draft - This can be several different things
• Dictated, transcribed or typed entry by a provider that has not yet been signed, but is available to other viewers of the EMR.  This is an option available to the provider in the Status sign menu
• Nursing only notes associated with an encounter such as PFSH, colonoscopy instructions
• In Process - This can be several things
• Encounter document started by nursing, not yet completed by the provider
• Dictated, transcribed, or typed entry by a provider that has not yet been signed, and is not available to other viewers of the EMR.  This is an option available to the provider in Status sign menu.

At the top of the list of progress notes for the patient are several toggle buttons to help sort the lists. 

• Progress notes - Notes associated with an encounter, i.e. clinic notes, encounters, history, lab work, imaging studies
• Chart notes - Notes not associated with an encounter, i.e. chart note, general request, patient call, patient question, rx refill, rx question and other types of notes created under the New Note tab on the summary screen