Getting Started in Discharge Summary Note

1. Top Bar Navigation: This Top Bar is the Note Navigation Timeline. Once you Fill in the Start Time and click Start Note All of the options 1-7 will expand. Clicking any of the Options will navigate you to the page.
   
2. Chart Detail Section: Click this button to open the Chart Detail Section and you can view items such as AIMS, VITALS, Face-sheet etc.
   
3. Service Date: This will default to Today’s date, clicking the calendar icon will allow you to make any adjustments to the service date.
   
4. Start Time: You can enter the Start Time manually by selecting the field, or you can click Set to Current Time (Located Underneath Field) and it will pull your computers' current time.
   
5. End Time: This field is not required to start the note.
   
6. Discharge Date: Here you can enter the Discharge date for the patient. 
   
7. You can click the Start note button to continue the Discharge note. 
   

Managing Progress Note Auto-Saves

1. Progress Note Auto-Saves: This section contains all Progress Note Auto Saves (Notes & Evaluations) & Note Auto Saves (All Notes Save every 60 seconds)
   
2. Note Type: This field notates the note type (Evaluation, Progress Note, PCP 2.0)
   
3. Patient Name: This field contains the Patient that belongs to the note
   
4. Action: Click Choose Action to Edit or Delete the note.
   

Managing Progress Note History

1. Progress Note History: This section contains Note History for the selected patient (Psych Note, Eval, PCP 3.0)
   
2. Progress Note Type: The default selection is My Notes but clicking the drop-down will allow you to filter by several criteria types.
   
3. Days Back: This field will allow you to narrow the note selection by how many days back the Service Date was for the Selected Patient.
   
4. Search Progress Note: Clicking this button will allow you to search for a Specific Note.
   
5.  Action: Once results have been returned you can click action on any note to: Amend, Edit, Print and View. 
   

History

1.  History: The active tab will highlight in a Darker Blue color to indicate what tab you are working inside of. Simply Clicking any of the other tabs will navigate you to the appropriate section.
   
2. Admission History: In this section, you are able to free text admission history notes or use historical notes to add in this section. 
   
3. Book Icon: Click on this book Icon will expand a list of all previous notes entered by any previous provider that entered in information on the active client.
   
4. Physical Exam/Labs/Vitals: In this section, you are able to free text Exam/Labs/ and Vitals information or use the Book Icon to add previous notes used. 
   
5. Hospital Course: This is a free text section that allows you to fill Hospital course information. 
   
6. Previous or Next: these buttons allow you to move to the next section of the note or go back. 
   

MSE

1. Save Template: Clicking Save Template will save all the MSE selections shown. Allowing you to create a template that will appear for each patient you see.
   
2. Clear Template: Pressing Clear Template will remove your active template that populates for each patient you see.
   
3. Load Previous MSE: This button will pull all the previous MSE selections from the active patient’s previous encounter.
   
4. Clear MSES: This will remove all field selections from the MSE section.
   
5. Selection: Clicking the field Age Appropriate will select the value for Fund of Knowledge
   
6. Free Text: All the MSE fields allow you to free-text anything that would pertain to its corresponding section.
   
7. Multi-select: Any field name with a “(*)” next to it, indicates that you can select multiple values. Simply hold Control on your keyboard and click each value you want to select.
   

Discharge Info.

1. Discharge Primary Diagnosis: This section allows you to find and add primary diagnosis.
   
2. Secondary Diagnosis: This section allows you to find and add secondary diagnosis.
   
3. Tertiary Diagnosis: This section allows you to find and add tertiary diagnosis. 
   
4. Discharge Medications: This is a free text section allowing you to add any medication information. 
   
5. Discharge Plan: This is a free text section that allows you to fill in a discharge plan. 
   
6. Book Icon: Click on this book Icon will expand a list of all previous notes entered by any previous provider that entered in information on the active client.
   

Labs

1. Filter: Selecting the filter field will allow you to select: Past 1 Year, Past 6 Months, Most Recent.
   
2. Returned: Selecting the checkbox, “Only show lab orders with resulted returned” will only show labs with results.
   
3. Requested By: This field will show you who ordered the lab
   
4. Lab Results: this column shoes if labs were returned or not returned.
   
5. Action: You can select Acknowledge Lab, Associated files or Print lab.
   
6. Add a Lab: Clicking on this link will open a new Laboratory stand-alone page where you can add a new lab. 
   

Prescriptions

1. Refresh Icon: Any new prescriptions added since the note was started will not appear until you click the refresh icon.
   
2. Prescriptions: This table will list all of the patient’s active prescriptions.
   
3. Open Prescription Sheet: Click Open Prescription Administration Sheet Page to manage the active patients’ prescriptions (Prescribe New, Refill, D/C).
   

 Services

1. Service Site: Select the site where the encounter took place
   
2.  Physician: This field is not editable, just informing you of the Attending Physician.
   
3. Save incomplete: This button will allow you to save the note to return later and edit. 
   
4. Pend For Review: This will allow you to pend the note to be reviewed. 
   
5. Clear note: this button will clear all fields.