Notes & Documents - Frequently Asked Questions

This quick guide answers frequently asked questions about Notes & Documents in VieCure. It covers writing and approving notes (including scribe and co-sign workflows), the two note views, dictation, macros, note templates, faxing or printing a note, and uploading and managing documents in the patient chart.

 How do I generate progress notes, nurse notes, etc.?

Notes are created from the patient's Notes & Documents screen using the New Note button below the patient tile. Each note is based on a note template, so the type of note you get (progress note, nurse note and so on) depends on the template you choose.

• Form View — Shows the sections built into the note template, with a faxing section always available.
• Text editor view — Click the T icon in the top right of the note area. Your entered data is kept when you switch between the two views.
• Approve — When the provider approves a note, it becomes a document in the patient's Notes & Documents list.

 How do I create a note template? (4x Training > Product Handoffs)

Note templates are built in a note template editor that has its own text editor page. Template creation is an administrator task, and access is controlled by a note template admin permission.

• Sections — The sections you build into a template appear in Form View when users write a note.
• Faxing section — Notes always show a faxing section in Form View. The ability to hide this section at the template level has been requested and is planned for future development.

 What is a macro and how do I create and use them?

A macro is a shortcut. You type a short trigger code, and it expands into your saved text, so you do not have to retype common phrases in notes.

Create your own macro

1. Open Macro Management from your user settings.
2. Create a personal macro by entering a trigger code and the expansion text. The screen checks the format, length and duplicate codes as you type.
3. Save it. Changes work right away, with no need to log out and back in.
4. Edit or delete — You can edit or delete your personal macros. Delete asks you to confirm.
5. Organization macros — Administrators with permission can create, edit, inactivate and delete enterprise macros in the Macro Management area of system configuration (under Library). You see these as read-only.
6. Same code, two macros — Your personal macro is used, and the enterprise macro is overridden. The list shows which one is active.
7. Find a macro — Search by code or content.
8. Today's date — Macros can include a dynamic "Today's Date" value.

 A patient says labs were drawn at an outside facility and faxed over, but I don't see them in Documents. What do I check?

1. Check the Inbound Faxes queue (New tab) for the fax. Inbound faxes do not appear in the patient's Documents until they are filed to the chart.
2. If the documents are there, open it and file it to the correct patient.
3. Check the Archived tab in case it was archived by mistake.
4. Confirm you have Inbound Faxing access. It is controlled by user role security, so you will not see the queue without it.
5. Once filed, the document has status Valid, or Valid: Pending Acknowledgement if someone was assigned to acknowledge it.

 How do I type a note, update Patient History (HPI) and use dictation in the same note?

• Type a note — Use the Form View or the text editor (T icon). Both edit the same note.
• Dictation sections — In Form View, a dictation section is a text box with Insert Previous and Save buttons next to the section header.
• Insert Previous — Opens a window listing the patient's earlier entries for that section. Filter by author or Date of Service, select an entry, then click Insert to place it in the text box.
• Save — Saves what is in the text box as a new entry for the note's Date of Service.

 I typed a note in the wrong patient's chart. How do I correct it?

If the note is still in Entered status, the author can edit, save or delete it. Delete the note from the wrong chart and re-enter it in the correct chart.

 How do I document a note with multiple authors (MA starts, scribe documents, provider finalizes)?

Use scribe mode. It is available to users with scribe permission.

1. Open the note and enter scribe mode.
2. Choose the provider you are documenting for from the list of internal providers at the active facility (alphabetical, with the option to favorite)
3. Document the note. The scribe can edit, save and delete the note while it is Entered.
4. Click Save. The scribe cannot approve.
5. The provider (author) finds the note on their worklist, reviews and edits as needed, and approves it.
6. What shows — The provider is listed as author with a "Scribed" badge. After approval, only the provider signs. The scribe's name is not on the note, but the history log shows the scribe created it.
7. Co-signature — If an APP needs supervising physician sign-off, the note shows Assign Cosigner and goes to Pending Co-signature until the co-signer approves.

 A note was approved and test results came in afterward. How do I append the note and change orders?

What is supported: orders are managed on their own, so you can place or change orders from the patient's chart independent of the note.

 How do I print or fax a note?

Fax at approval

1. Open the note's Faxing section (always present in Form View) and select the providers to send to. You can also choose a one-time recipient or add a provider to the chart.
2. Approve the note. The fax sends automatically to the selected providers, and the approved note shows a CC line with their names and roles.
3. You see a confirmation message.
4. If you save the note without approving it, nothing is faxed. If no providers are selected, nothing is faxed.
5. Faxing still happens if the charge capture window is dismissed.
6. For a note waiting on a co-signer, the fax is sent once the note is approved.
7. For faxing other documents, see "How do I fax over paperwork to another facility?" in the eFax guide.

 How do I add documentation from a recent ER or hospital visit?

Upload the records as a document on the patient's Notes & Documents screen using the Upload button below the patient tile. If the records came in by fax, file the fax to the chart from the Inbound Faxes queue.

• Supported file types — PDF, TIFF/TIF, JPEG/JPG, PNG and DOC/DOCX.
• Assign someone — If you assign a user during upload, the document is Valid: Pending Acknowledgement until they acknowledge it. Otherwise, it is Valid.

 Documents were uploaded to the wrong patient. How do I move or correct them?

Documents can be renamed or voided from the document viewer.

• Void — Use it to remove the document from the wrong chart.
• Then upload the document again to the correct patient.

 A new referral's records arrived as one large PDF. How do I upload and split the PDF by document type?

Upload the PDF to the patient's chart from the Upload button on Notes & Documents. If it arrived by fax, open it from the Inbound Faxes queue, where you can view and select pages.

 How do I scan or upload insurance information and other documents, and take a patient picture?

• Upload documents — Use the Upload button on Notes & Documents. Supported file types are PDF, TIFF/TIF, JPEG/JPG, PNG and DOC/DOCX.
• Patient picture — A patient photo is part of the Demographics design.