Write a New Progress Note

To write a new note, use these steps:

1. On the Notes tab, select New Note or select Action | New Progress Note....

Note: If this visit is undefined, you will be prompted for encounter type and location, clinician, date, and type of visit, such as Ambulatory, Telephone, or Historical.

2. In the Progress Note Properties dialog, select the following so that the note may be auto-saved:

Note: The Progress Note Properties Dialog is where the user selects the progress note title, date, author, and in the case of a consult or patient record flag note, the consult number or patient record flag action for the note.

a) Progress Note Title (e.g., General, SOAP, Warning, etc.). Additional items will appear on the dialog for titles that require entry of a cosigner or an associated consult.

b) If necessary, change the note date by clicking the button next to the date and entering a new date.

c) If necessary, change the note author by selecting the author from the Author drop-down list.

(Note about providers with similar first and last names.)

Note: Occasionally a problem occurs if a cosigner's access lapses and they have become "disusered". If this occurs, you can select OK and proceed with that selection or select Cancel and choose another cosigner.

d) If the note is to resolve a consult or to document a patient record flag, select the consult number or the patient record flag action to which the note should be linked. To help users select the correct consult when a title that will resolve a consult is selected and a consult is available to resolve, a Show Details button that brings up the details of the consult is available.

Note: If the user attempts to change the characteristics of a PRF note and has highlighted an action that reads Yes under note, CPRS assumes that the user is trying to link to an already linked action and will not allow the change to continue. However, if the user removes the highlight from the Yes action, the changes can occur.

e) Select OK.

3. In the main text box, enter the content of the note using one of more of the methods below:

o Copy and paste from other documents

o Type in text

o Insert predefined text from templates.

a. Select the Templates drawer.

b. Locate the template you need.

c. Double-click the template, drag-and-drop the template into the document, or right-click and select Insert Template. (It will be placed where the cursor is.)

d. Repeat steps b and c as needed.

Note: If you need to view the consult details while writing a note, bring up the popup menu by right-clicking in the note editing pane and choosing View Consult Details or using the shortcut Shift+Ctrl+U.

Note: Spell checking and grammar checking are now available in the CPRS GUI.

4. After you enter the note, if you select Encounter, you can enter encounter information for the visit.

Diagnosis, procedure, and Visit Type are required. The check boxes are based on the Encounter Form defined for the Progress Note Title you select. When you click on Other Diagnoses or Other Procedures, a Lexicon look up (terms with their corresponding ICD or CPT codes) is displayed for you to choose from.

Note: When finished, you can continue working or select an item from the Action menu, such as Sign Note Now..., Save Without Signature, or Add to Signature List.