This article describes how to update a patient chart for an initial visit, including opening notes linked to appointments, selecting the correct note template type, and reviewing other important information on a patient chart. It provides a video and helpful tips for completing your notes.
Video demonstration
Helpful tips
- You must fill out all fields highlighted in yellow
- The psych intake form will pre-populate your initial visit note template.
- Your initial visit note will populate follow-up note templates.
- Tips for specific tabs:
- We have the Columbia Suicide Scale for each visit and do this in-session
- CC/HPI/Risk/History tab: should be mostly pre-populated if your patient did the intake, but take 5 minutes in session to confirm & add info
- Review of Systems: FYI - this defaults to Normal
- Plan & Assessment:
- We have dot phrases for general criteria by condition, but these must be tailored to each individual: Standard Dot Phrases.
- If you would like any dot phrases added to AMD, please submit your request using our Psychiatric Services Providers' form, which is available under Web Links in the EHR.
- If you would like any dot phrases added to AMD, please submit your request using our Psychiatric Services Providers' form, which is available under Web Links in the EHR.
- If you have a diagnosis in HPI already, you don’t need to copy/paste over (but you can if you want). The diagnosis just has to be tracked somewhere!
- We have dot phrases for general criteria by condition, but these must be tailored to each individual: Standard Dot Phrases.
- Supplemental template for ADHD available for use
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Sign your note when you’re done editing it using sign-off code “1234”. A charge slip will be generated automatically.
- Note: If there’s an open chart that doesn’t need to be signed, delete it (so you can avoid having a list of open, unfinished charts!)
Updated