To add more information or to clarify an error:
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In order to create a linked note from within a patient’s chart, providers can find the session in the timeline, click the three dots next to the appointment type, hover over Add Linked, and then click Patient Note:
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Make sure the template type reads "Psychiatric Services"
- Make sure the date on the Info tab corresponds to the date of the appointment. This way, the note will be associated with the correct date of service.
- Then select "Psych - Blank Note" as the note template.
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In the Purpose of note field, type in "addendum" or "clarification"
- In the free response box, document the current date and time and state the reason for the addendum or clarification referring back to the original entry
- Type in your name and select your license
- Always select the current date/time and click Sign
- Type in the password, 1234, and then click Sign again
Example of an addendum:
Example of a clarification:
"CLARIFICATION: I reached out to the patient to inform them that I was sick and therefore needed to reschedule our session. We rescheduled this session for the following Monday 1/22/2024. The patient reports no need for check-in and is satisfied with the new scheduled appt."
Example of an error:
"ADDENDUM: For the Initial Assessment dated March 8, 2024, I’d like to record that the medication sent was escitalopram 5mg 1 tab po daily #30, not escitalopram 10mg 1 tab po daily #30 as incorrectly charted in the plan.
- Sign the Patient's Note
Note: Do not generate a new charge slip for a supplement or clarification.
Updated