Clinical Notes

Work smarter by using autotext .dot phrases to create your note. View the .dot phrase library, or create your own .dot phrase.

Pull documentation from your patient’s chart to dynamically create your note. View this 4 minute demo to see how: Creating your note with Dynamic Documentation

Need to document a confidential note? How to Document Confidential Notes

See what’s included in these Dynamic Documentation note templates:

• Consultation note
• History and Physical (H&P) note
• Inpatient Progress note
• Narrative Summary note
• Simple Clinic note

  Orders

As  you care for your patient, you will review and manage the patient’s orders. View this eLearning to become familiar with Order Entry and Favorites. Choose the topics you want to review, including how to view orders, place quick orders, locate and place orders, add and find favorites, and add orders to a powerplan.

  Medication Reconciliation

Compiling a list of the patient’s historical medications and prescriptions helps ensure an accurate and complete home medications list is available at all transitions of care. Learn more about Home Medication List and Medication Reconciliation

  Problem List/Diagnosis

Provides a concise view of a patient’s health status. Review and Update the Problem List/Dx.