1. Category or All: You are able to change the view of the PCP chart to either be category based as the image above or you can view All sections of the PCP note in a vertical format. '
   
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.  Top Bar Navigation: This Top Bar is the Note Navigation Timeline. Clicking any of the Options will navigate you to the page. Example: Click “4. Questionnaires” will navigate you to the section in the note.
   
4. Service Date: This will default to Today’s date, clicking the calendar icon will allow you to make any adjustments to the service date.
   
5. 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.
   
6. End Time: This field is not required to start the note.
   
7. Here you can begin to enter your notes for a patient such as Chief complaint, the reason for admission, family history, social history, general appearance, and surgical history.    
   
8.  You can click the Next button to continue the assessment.
   
9. Save Incomplete, Save Complete, Reset: You can save complete, incomplete, and reset the nurse assessment note. 
   

1. Category or All: You are able to change the view of the PCP chart to either be category based as the image above or you can view All sections of the PCP note in a vertical format. '
   
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.  Top Bar Navigation: This Top Bar is the Note Navigation Timeline. Clicking any of the Options will navigate you to the page. Example: Click “4. Questionnaires” will navigate you to the section in the note.
   
4. Back/Front body check: Here you can freely mark/draw the skin and body check done on a patient. Use your mouse to click and mark on the image. 
   
5. Color indicator: this section allows you to choose the color that correlates to the mark done on the image.  For example, the color dark green means that you marked the body image for Rashes. 
   
6. Comments: this is a free text box that allows you to input any comments related to the assessment of the body.
   
7. Undo/Reset: this will allow you to undo any changes or completely reset the skin and body check to start over.
   

1.   Assessments: 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. Template: Clicking this drop-down will allow you to select which template you would like to begin review. Once selected, all the categories corresponding to the selected template will populate.
   
3. Save Template: Clicking Save Template will save all the ROS sections shown. Allowing you to create a template that will appear for each patient you see.
   
4. Clear Template: This will clear out any Template that you have saved in the past.
   
5.  You are able to select 3 Exam options to fill in:  All Reviewed and are Negative: You can select this option if the exam was negative or not done, this will clear all the Exam options above. All Reviewed and Negative, Except: this allows you to select certain ROS needed. Display all ROS's: This will Display all ROS's that can be selectable. 
   
6.  After selecting a ROS (Example: Skin), all the categories will appear. To select an appropriate category, simply click on the category name. Once you click on the category it will darken the background behind the text.
   
7. Free-Text: With any category selection, you can free-text any additional details you would like to notate on the category selection.
   

1. Substance Abuse Table: this table allows you to fill out substance abuse information.
   
2. Primary Drug: this is drop down menu listing several drugs that can be selected. 
   
3. Frequency: this is a drop down menu that allows you to select the frequency of use. 
   
4. Route: this is a drop down menu that allows you to select the route the drug was administered by the patient. 
   
5. Age of first use: this us a free text box that allows you to input the age of patients' first use of a certain drug. 
   
6. Clear MSES: This will remove all field selections from the MSE section.
   
7. Selection: Clicking the field Age Appropriate will select the value for Fund of Knowledge
   
8. 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
   
9. Free Text: All the MSE fields allow you to free-text anything that would pertain to its corresponding section.
   

Questionnaires

1. Questionnaire: 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. History Table: this will display any previous questionnaires submitted. 
   
3.  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.
   
4. Checkboxes: Input the answers for the questions in the checkboxes.
   
5. Previous and Next: this allows you to move from one questionnaire to the next or to the one before. 
   
6. Previous and Next: you can click the Next or Previous button to continue the Nurse Assessment
   

Services

1. Services: 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. Service Site: Select the site where the encounter took place.
   
3. Provider: This field is not editable, just informing you of the Attending Physician
   
4. Service List: Select the appropriate service code for the encounter.
   
5. Start Time: List the Start Time for the Service Code.
   
6. End Time: Enter the End Time for the Service Code or click Set to Current Time to automatically populate the current time from your PC.
   
7. Place of Service: this allows you to select the place of service from the drop down menu.
   
8. Comment Box: free text box for any additional comments. 
   
9.  Previous: this allows you to move back to the previous pages in the Nurse Assessment note.
   
10. Save incomplete, Save complete, and Reset: this will allows you to save the note incomplete to return later and finish or you can save complete. The reset button will clear all fields in the nurse assessment note so you can start over. 
    

Please Note: If you select multiple service codes, please ensure that they do not have any overlapping start & end times.

Managing Note Auto-Saves

1.  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