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If a free text field already exists in a section, position the cursor in that field and type or dictate in your entry. 4Ĩ EMR Provider Documentation ADDING FREE TEXT Working in free text mode enables you to enter free text in the note. Click the Undo icon to add a deleted item. Click the X icon on the section or subsection. Deleting a section removes all data, the X image, the bent arrow, the heading, and the entire section, including any subsections. NOTE: When the cursor is hovered over a section, the border and gray background display behind all contents in that section to help you understand what will be removed. 3ħ Dynamic Documentation REMOVING A NOTE SECTION OR SUBSECTION (Continued) To remove a note section or subsection that you do not want to include in the note: Position the cursor over the section or subsection you want to remove. They are only visible when you hover the pointer over the section or subsection and neither are visible in the final note. REMOVING A NOTE SECTION OR SUBSECTION Each section and subsection contain a bent arrow and an X icon located to the right of the section or subsection title. The user will dictate using Dragon, or free text into the remaining fields. Items documented in the patient chart already (allergies, diagnosis, medications, measurements, orders, problems and vital signs) will automatically pull into the note. 2Ħ EMR Provider Documentation creating a note (Continued) The selected note will open. Double-click on the appropriate Note Template at the bottom of the page to select it. Note: To create a Personal Note Type List, please see the Appendix. It is extremely important to choose the correct note type when creating a note as this will determine where it is filed in the clinical folders. Click the drop-down arrow to select the appropriate Note Type. Select Dynamic Documentation for inpatient documentation. Click the drop-down arrow to the right of the Add button. 1ĥ Dynamic Documentation creating a note (Continued) NOTE: Providers who currently work in areas using PowerNote for documentation in the ED and Ambulatory Clinics will continue to use PowerNote in those settings, but will be required to use Dynamic Documentation for the inpatient setting. Click the Add button on the Documentation component of the menu OR the Quick Add button on the Documents tab of the Summary Views. Creating a Note Complete the following steps to create a new note: 1. NOTE: Users currently dictating notes through Nuance can continue to do so.

Users can choose to dictate into the note templates using Dragon or type directly into the note. Dynamic Documentation efficiently pulls data from the patient chart into the notes (allergies, diagnosis, medications, measurements, orders, problems, and vital signs) and allows providers to create free text entries alongside chart data, for flexible and efficient clinical documentation.

All provider notes, including H&P s, consults, progress notes, pre and post procedure, operative and discharge summaries, will be documented electronically via the EMR. 1 User Guide EMR Provider Documentation April 2014 Volume 1ģ Table of Contents OVERVIEW.1 Creating a Note.1 REMOVING A NOTE SECTION OR SUBSECTION.3 ADDING FREE TEXT.5 inserting a free text field.5 modifying FREE TEXT.6 USING GLOBAL AUTO TEXT.6 formatting FREE TEXT.7 SAVING A NOTE.8 OPENING AN existing NOTE.12 Modifying an existing note.13 overriding a locked note.15 ERROR A DOCUMENT.16 APPENDIX I: legend for dynamic documentation.18 APPENDIX II: AVAILABLE GLOBAL TEXT.20 APPENDIX III: TEMPLATES.21 APPENDIX IV: Creating a Personal Note Type List.22 APPENDIX V: co-signature matrix.22Ĥ EMR Provider Documentation OVERVIEW Dynamic Documentation is our electronic tool for provider documentation.

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