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Recording Plan EHR Information

  1. Recording EHR Plan InformationClick a patient in the EHR status window and click “View Exam”
  2. Click the Assessment tab
  3. Add or change treatments by clicking the large white area in the middle of the plan tab. Check or uncheck treatments in the pop-up window and click “OK” to save and exit the window.
  4. Add treatments from a macro by clicking the greater than sign at the top left corner next to the words “Treatment Macros” and select the macro name in the fly out window.
  5. Add frequency of care by clicking the drop-down menu labeled “frequency of care” and select frequency.
  6. Modify functional goals by clicking the drop-down menu labeled “functional goals” and select one or more goals from the list.
  7. Add Goals by clicking the drop-down menu labeled “Goals” and select a goal from the list.
  8. Add Prescribed Exercises by clicking the less than sign “< “in the upper right corner under the words “Prescribed Exercises” and check the box next to the exercise.
  9. Add comments or notes by click on the “new comment” button and type information into the pop-up text box. Click “OK” when done.
  10. Chang date of injury by clicking click the calendar icon within the drop-down menu labeled “date of the incident” and select the injury date.
  11. Sign and close note by clicking the button labeled “Digitally Sign and Close”.
  12. Print notes by clicking the button “Print Daily Note” select long-form or short form in the pop-up window. Click OK and follow the steps to print from your pdf viewer.
  13. Un-sign note by click “Un-sign” at the bottom of the window. IMPORTANT NOTE: It can be illegal to un-sign and change information in a patient’s notes after 24hrs from their visit date.  A record of your keystroke(s) is recorded in an audit report.  This report can be subpoenaed.  We suggest using the comment boxes in each window to record addendums.
  14. Print narrative reports by clicking the button “Narrative” and follow the printing steps in your pdf viewer.
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Next Recording Patient Medical History
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