Notes  

This article provides a walkthrough of the notes and data tag functionality within the VieCure Platform.

Creating a Note

Select the patient "notes icon" from the Demographics tile.

Select “+Note."

Select the appropriate Note type and Template.  The note will populate all the pre-built data fields.

The note will populate with the pre-built data fields unique to that specific note. Each pre built data field will pull the data automatically from the patient's chart.

The pre-built data fields save time and ensure accuracy by automatically populating information from the patient's chart. However, it is important for healthcare providers to review and update the information as necessary to ensure complete and accurate documentation.

Example procedure "New Patient Consult Note"

Users can also generate a blank note by selecting a note type and selecting the “Select” button without selecting a template on the right side of the screen.

• Users have the ability to adjust the Date of Service when generating a notes. The current date will auto populate. Users may also select a previous or future date of service. 

When the note is completed the user can perform the following actions:

1. Assign - You can assign this note to another teammate or clinician for review and approval. The note will remain in a "pending approval" status.
2. Save - This will save the note within the patients chart. The note will remain in a "Entered" status. This status will allow users to make additional changes to the note.
3. Approve - This will approve the note within the patient's chart. Once the note is approved it can only be appended, copy or voided.

Assign a Note

With the note open, select the “Assign” button.

• Search or select the appropriate user and click "save".

Once the note is assigned, the Note will appear on the assigned user’s Quick View page to be actioned.

You can also view the assignee of the document from the My Notes page (Between the Author and Status Column)

You can also view the assignee for each document from the My Notes page within the patients chart (Between the Author and Status Column).

Linked Functionality: Home Screen

Void a Note

When you select the "Void" action the user must add a reason for voiding. When a note is Voided, the user will be taken back to the Notes tab. Void notes are automatically hidden.

To see Voided notes, select the Status filter.

Select “Voided.”

The Notes list will now include any notes previously Voided. Voided Notes will display with a “Strike Through.”

View Note

To view any note select “View/Edit” from the Action tab of the Notes page.

Copy Note

To view any note select arrow beside the “View/Edit”  action tab of the Notes page.

When the dropdown opens, select “Copy.”

When prompted, select the Note Type you want to copy the note to.

The note you chose to copy will then be copied to the notes section with the selected note type.

Opening a Note in a New Window

To open a note in a new window, select the "notes" tab on the demographic tile.

Open or create a new note for the patient.

Once open the note will display and give the user multiple options.

Select the "Open in a New Window" icon.

This will pop-open a new web browser window, allowing the user to simultaneously edit the patient note while also viewing the patient record.

Creating a Quick Note

A quick note is a brief patient summary including impression and plan which can be sent to a referring or other provider after the consult or progress note has been completed.  The Quick Note must be set as a Favorite.

To create a quick note select the “Manage Templates” button in the right side of the screen on the Notes and Document page.

Select one of your favorite Note Templates.

Select “Set as QuickNote.” The Quick Note action will be promoted the next time this specific note template is created and approved.

Using a Quick Note

To use a Quick Note you must navigate to the patients notes & documents screen.

Select the approved note you would like to add

Select “Quick Note.”

The Fax Modal will open and user can fax the document following the faxing medical records process.

Linked Functionality: Viewing, Uploading, and Faxing Medical Records

Once the document is faxed, Quick Notes will appear under the original note.

Scribe Functionality

This section of the article demonstrates how to create a note in scribe mode and discusses the scribe functionality within Viecure.

Creating a Note in Scribe Mode

Select the patient "notes" icon.

Choose the suitable Note type, then position your cursor over the template intended for your note and click the "Scribe" button to generate a document in scribe mode.

If you click anywhere outside of the "Scribe" button, than the new document will open in the standard document mode.

A Pop up notification will prompt the user to select the provider you are scribing on behalf of. Select the provider from the drop down list and select the "Create Note" Button.

The new document will open in scribe mode which is viewable in the top left corner. You will also have the ability to change the Date of Service, and update the Provider you are scribing on behalf of. The user will have the same experience in scribe mode as they will in the regular note mode.

Upon completion of their documentation, the end user may forward the note for approval to the provider by clicking the "Send" button, which takes the place of the "Assigned" button when in Scribe mode.

Approving a Scribed Note

When a document has been sent for approval, both the scribe and provider will receive a notification, which can be viewable in their quick views.

The document can be approved by the scribe or provider

You can open the note for approval by clicking the"View Note" Icon, or additional actions are available in the drop down.  

Once the Note is open, the provider will be prompted with the same actions in scribe mode as regular note mode.

When you open a document in scribed mode you will have the ability to view who created the document in the "Scribed by".

Once the Note ready to be approved, click the "Approved" button in the upper right portion of the screen.

Viewing a Scribed Note

Select the patient "notes" icon.

Navigate to the Note/Document you would like to open and click the "view" button.

A new scribe column has been created which shows if the document was created in scribe mode. Unapproved notes can be opened in Scribe mode by selecting "Edit in Scribe Mode" from the drop down menu. Approved documents are unable to be edited.

Templates

This section of the article shows users how to build and maintain Note Templates.

Creating a Note Template

Select the patient "notes" icon.

Select the "Manage Templates" button on the right side of the screen.

Select the appropriate Note Type, then select an existing template, or the “+ Template" button to create a blank template.

Adding Data Tags to a Template

Users can manually type information within the note template as well as add “data tags” from the data tags column located on the left side of the screen.

Removing a Data Tag from a Template

Hover your pointer over the data tag you would liked removed and right-click and select “delete field.”

Collapsing and Expanding the Data Tag Menu

VieCure end users have the ability to hide and expand the data tag menu when opening, editing, viewing, and adding new notes. If the data tag menu is previously opened for the user, the menu will display the next time the note is opened. If it was previously collapsed, it will display as collapsed.

 To collapse the the data tags menu, select the "Collapse" icon.

This will collapse the data tag menu and only display the note text area.

To expand the data tag menu, simply select the expand data tags icon on the left side of the screen.

Saving a Note Template

Prior to saving your new template, you should name the template and than press the "Save" icon.

Sharing a Note Template

To share a note template with other users, select the “Share Template” button and save. All new notes are set to private by default.

Editing an Existing Note Template

Select the patient "notes" icon.

Select the "Manage Templates" button on the right side of the screen.

Select the Note Type, and the template.

Once you have selected the appropriate template, select “Edit.”

The selected template will open. 

Users can manually edit information within the template, as well as add or remove “data tags.”

Adding Data Tag to Footer

When editing a document click the "Insert" action on the toolbar

Click the "Footer" Icon and than select "Edit Footer"

Insert appropriate data tags into the footer.

This will allow each document to have patient identifiers on the bottom of every page.

When the revisions are complete, select the Save icon to save the edits.

Cosigning a Note

VieCure physicians have the ability to sign-off on patients' notes for Secondary providers they are supervising. This feature exists for any provider with the following credentials: M.D, D.O, or M.B.B.S

To enable this feature open the users profile under "System configuration → User Maintenance → Users"

Select "Authorized Cosigner"

Once the note has been created and is ready for Approval, click the drop down arrow beside the Approve button. Users will have the ability to select "Approve & Send to Cosigner". The ability to send to a Cosigner is only available to APP's. 

Once approved you will be prompted to select the user who can cosign the note.

After you select the user, a notification will prompt on their Home Quickview. If the cosigner needs to be reassigned, the user may navigate to the note and choose to Send to Cosigner. A new cosigner may be selected and the Quickview will update to the new assigned user.

Notes needing cosigning will be indicated beside the patient's name. 

The assigned user will have the ability to open/view and approve the note.


 

Duplicating a Note Template 

Select the patient "notes" icon.

Select the "Manage Templates" button on the right side of the screen.

Select the Note Type, and the template and select “Duplicate.”

A New Note Template with the information from the duplicated template will populate with the name “Copy of (selected note).” Users can manually edit the information within the template, as well as add or delete data tags.

Rename the note template and click "save."

Deleting a Note Template

Select the patient "notes" icon.

Select the "Manage Templates" button on the right side of the screen.

Select the Note Type, and the template and select “Delete.”

Favorite Note Templates

Select patient "notes" from the Demographics tile.

Select “+Note”.

Select a Note Type and choose the “Star” icon to select a note template as a favorite.

Once added as a favorite, that template will display in the top note type section of “Favorites.”