About the Note Writer Applet
Applet Main Page
Tap the Note Writer icon to launch the Note Writer:
- Note tab
- Link tab - note must be linked to a clinical event to sign & submit
- Existing Outpatient Clinic Appointment
- Existing Hospital Admission
- New Visit
- Encounter tab
- Visit Type
- Related To
- Providers
- Diagnosis
- Procedures
- Sign
Note Writer – Note tab
- Title – User must select a pre-defined note title in order to sign & submit the note. It may be saved as draft without a title selected.
- Note body – User may enter text or copy/paste in plain text; no current limitation to size of note.
Note Writer – Link tab
- Clinic Appointment – selecting this option will display a list of existing appointments for the patient that can be linked to the note.
- Hospital Admission – if the patient is currently admitted, the option will be default selected; user has the option to change to any of the available options. If the note is linked to the current admission, the encounter form is optional. However, once data is added to the encounter form (even if admitted), the entire form must be filled in to sign & submit the note.
- New Visit - selecting this option will allow for the creation of a New Visit for the purposes of submitting the note. However, no appointment record is created for this visit (mirrors CPRS functionality).
- Time of Visit – defaults to "Now"; can be adjusted
- Date of Visit – defaults to "Today"; can be adjusted
- Location – Auto-complete data entry field for the Clinic to be associated with the note
- Historical Visit – Serves the same function as the identical button on the CPRS encounter form
Note Writer – Encounter tab
Required for all notes unless the following is true: (a) the patient is currently admitted, and (b) the note is associated to the current admission; collapsible headers for each of the areas
- If the patient is admitted, the encounter form can be skipped; however, if any data is added to the form, the entire form must be completed as if documenting an Outpatient Clinic Visit
- Visit Type – Required, unless the clinic has not defined one; Visit Type (E&M code) OR Procedure Code is required to complete the encounter information
- Section – required where specified
- Modifiers - optional
- Providers – Primary Provider is required, defaults to the logged in provider. User can add more if necessary, and change the Primary Provider designation.
- Related To – Require if applicable, options are greyed out/inactive if not applicable. If active, user can set to Yes/No.
- Diagnosis – Required. User can select multiple diagnoses to add to the current encounter.
- Add Diagnosis - Auto-complete search for Diagnosis – three character minimum to commence search; can search by text or ICD code; selecting item removes it from the displayed list, and adds to the current encounter
- Add to P/L – allows the user to add the patient's Problem List if new
- Primary – user can designate the Primary diagnosis for the encounter
- Problem List – displays the patient's current, active problems
- Select All – allows the user to select all current diagnoses in the encounter
- Deselect All – allows the user to de-select all the current diagnoses in the encounter
- Remove – allows the user to remove all currently selected diagnoses from the encounter
- Procedures – Required if Visit Type not selected. User can select multiple diagnoses to add to the current encounter.
- Add Procedure - Auto-complete search for procedures – three character minimum to commence search; can search by text or CPT code; selecting item removes it from the displayed list, and adds to the current encounter
- Modifiers – selecting the Modifiers button for a procedure displays a dialog of available modifiers for the selected procedure; multiple modifiers can be selected
- Select All – allows the user to select all current procedures in the encounter
- Deselect All – allows the user to de-select all the current procedures in the encounter
- Remove – allows the user to remove all currently selected procedures from the encounter
Note Writer – Sign tab
- When all required elements are present, Sign button becomes active
- Provides a preview of all data elements currently in the note
- Sign – user then enters eSig code and submits signed note to VistA
- Cancel – Cancels the sign action (note remains in a draft or in-progress state)
Save and Delete Buttons
- Save button allows an in progress note to be saved
- Delete button allows a in progress note to be deleted (once signed the note cannot be deleted)