Completing a Progress Note

Introduction

After creating your census for a date of service (DOS), you may start your note for your patients. This article will focus on how to complete a progress note.

Table of Contents

1. Creating a New Note

2. Selecting a Template 

3. Completing the Progress Note

4. Signing the note

5. Make changes to your signed note

Creating a New Note 

To create a note for a visit, click on the Open Note tab indicated by the “+” sign.

You are then taken to DN’s note editor with a popup window to select a template or a note to start your note with:

Selecting a Template 

If you ‘d like to start your note with a blank page, click on the paper icon next to “Blank Template” ; we typically don’t see lots of providers start a note from scratch with a blank template.

DN has created a few templates for you to start your note with. Your organization’s administrators probably have pre-configured templates for you as well. To use a template to start your note with, go to the “Select from library” dropdown menu and choose appropriate template. For example, during an initial evaluation, you must have an initial template for your specific facility. If the note is for a follow up visit, please select the associated follow up note template to allow your data to pull forward into the follow up note, if the template utilized the .prevnote smart phrases.

You might notice there are “[S]” and “[U]” in front of the template titles. [U] means "user-defined" and [S] means "system-defined" in DoctorNow. A user-defined template is made by a user; whereas a system-defined template is made by your company’s administrators. Please note that your organization might not user-defined templates in your system.

The other 2 template options are “Select from Recent Notes” and “Select from Associated Provider of *** facility”, which will allow you to choose from one of your previous notes from the selected patient, or a previous note from a provider that you are associated with.

Completing the Progress Note 

Using the *** feature

You might see a number of *** in the loaded template. These are areas that you are expected to fill in with free-text, and you must address all of the *** before you are allowed to sign the note. There are two convenient options to navigate through all of the *** in your note:

• Using the tab button on your keyboard
• Clicking on   at the top left of the screen

Using the dropdown menu

You might encounter dropdowns menus in your note templates, which are highlighted in red, with pre-configured options embedded for you to choose from in a template. See an example below:

Similar to the ***, you must address all of them before you are allowed to sign the note.

Signing the note

All *** and dot phrases must be removed or completed before you can sign the note. When you have completed your documentation, simply click the blue “Sign” button at the top right of the top of your screen to sign your note. Only the creator of the note can sign the note.

Make changes to your signed note

Once your note is signed, you cannot edit or delete it. If you’ve made a mistake and need to correct it, please click on the “Create Addendum” button, which will open a free-text field for you to describe what changes you need to make. Only the creator of the note can create an addendum to the note.

An example of an addendum can look like this:

FAQs:

• Q: I created and signed a note by mistake - how do I deleted/edit it?
  • A: Please follow the "Make Changes to You Signed Note" section to create an addendum to your note.

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