Overview: Steps to create a message or chart note from the New Note screen.
Location: Access from the New Note button from the sidebar menu in the patient's electronic medical record (EAR).
Buttons: Click on the New Notes button in the sidebar menu of the EAR, which will open up the New Note screen.
The window at the top of this screen displays patient contact information. If this needs to be changed, click on the blue Edit button in this box, and the Edit Preferred Phone popup window appears. Change the information as needed and then click the Save button to save the changes and close the Edit Preferred Phone window. Most of the time, the phone numbers will be correct, and will not need to be edited.
The next box down shows the priority that will be attached to the message. The default is Routine priority. This can be changed by clicking on the nearby blue Edit box to open up a list of choices that include Stat, Urgent, Routine, and None. Click on the appropriate entry to select the choice.
The next box down is the main entry box for the chart note / message. This is where you will enter most of the information to create the message.
To enter the type of chart note, click on the Note Description field. This will display a list of preentered note types to the right of the field. Select a type as appropriate, or enter in a free text entry to describe the note type. An example would be "Chart Note-Colonoscopy Report".
Select the appropriate provider that the chart note or message is to be associated with. If you are a provider, this should default to your name. If you click on the Provider field, a list of providers in your workgroup will be displayed that you can select, which are mainly providers in your clinic. You may have to click on the Next or Previous buttons to navigate through this list. Click on the appropriate name to select that provider. Also, you can begin typing in the name of the provider and the list will narrow down to the appropriate selection after three letters, allowing you to click on the appropriate name.
The Location field will have a default value. If this is not correct, change the location by clicking on the Location field, and then select the location from the list that appears just to the right of the field. You may have to click on the Next or Previous buttons to navigate through the list.
Next, choose the correct routing, by clicking on the Route to Worklist field, and then selecting the appropriate worklist from the list that appears just to the right of the field. Use the Next or Previous buttons to navigate through the list.
Selecting "File Directly to Pt Record" will file the chart note directly into the electronic chart without routing the message to anyone else. This message cannot be edited once it is saved, and is only viewable through the Practice Notes sidebar button. If you chose any other worklist option, then the system will route a message to the appropriate receiver.
If the suffix of the worklist entry is "-Nurse", the message will be routed to the nurse associated with the provider entered in the Provider field. If the suffix of the worklist entry is "-Prov", the message will be routed to the provider entered in the Provider field. If the suffix of the worklist entry is "-PFC", the message is intended to be routed to the receptionists. However, in our system, the receptionists don't have access to PWM and will not get the message.
If you want to send the message to another provider, for information only, click on the CC Provider field to bring up the workgroup list to select the receiving provider. The message will go to that provider's Desktop, but the receiving provider will not be able to take action on that task, or to route or forward that message.
To enter in the text of the message, click on the blue Edit button of the Message box. This will bring up the Edit Message popup window. Enter your text and then click Save.
When you have finished entering in the data for your chart note, then click the Save footer button to save and send the message. The Save button won't be active until you have filled in the Note Description, the Date, the Time, the Provider, the Location and the Route to Worklist fields. The current date and time will be filled into the Date and Time fields as the default values.
While you are creating a message, you will also have the ability to open up another window to view labs, orders, or other notes in another window.
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