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Addending a Note

 

This workflow will be extremely important in the PAU.  We often see patients and complete a preop evaluation.  However, there may be outstanding bloodwork, notes and imaging not available at the time of the assessment.

 

Similar to today (process to be finalized), we will have to review abnormal blood work and any other docs requested at the time of the visit before the preop chart can be completed and signed off.

 

As such, you will have to access patient’s charts should you wish to modify the Pre-eval note.

 

To find the patient, select “ Patient Station

 

 

 

 

 

 

 

 

 

 

You need to enter THREE identifiers to locate a patient

The system will find the patient. Click “ Accept ”.

 

 

 

Navigate to “ Chart Review

 

You will be able to find the note under “Encounter”

 

 

Although it will probably easier to find under “Anesthesia Records” (less to sort through)

 

If you double click, you will may see the note but won’t be able to revise.

 

The key here is to “ RIGHT CLICK ” and select, “ Addend

 

 

The note appears with the option to “ Addend in Notewriter ”, click on the link

 

 

 

The note is now modifiable.

 

 

 

 

 

 

 

 

 

The abnormal results are free texted.  Make sure you click outside of any “blue” area (which represents a link) in order to get your cursor to appear so you can enter information.  In this case, I would highlight “Labs: No results found for this or any…….” , backspace to DELETE that statement.  “ Sign ” the note.

 

Another option would be to hit the “refresh all smartlinks” so that all the bloodwork is automatically brought into the chart. 

 

The finished note now has the abnormal results.

 

The bottom of the notes shows the “ Revision History

 

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