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Visit Note Documentation Guide- Using Clinical Profile documentation to facilitate charting

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Visit Note Documentation Guide- Using Clinical Profile documentation to facilitate charting

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Why should I keep the Clinical Profile up to date?

Keeping the Clinical Profile accurate and up to date will allow you to make informed healthcare recommendations. You can even reference data from the Clinical Profile into notes and visit notes to facilitate documentation. To learn more about adding data to the Clinical Profile, read out Clinical Profile Guide- A snapshot of the patient's health status article.


 

How does Elation help me avoid double documentation?

Any record in the clinical profile can be referenced into a note or visit note to facilitate documentation of a clinical encounter. You can click the "Actions" button next to any header to export the entire section to a note or visit note. You can also click "Actions" next to a specific record to only export that record to a note or visit note. Certain visit note formats also allow you to reference different sections of the Clinical Profile into your visit note with buttons directly within the visit note format itself. Review the various visit note formats in the Visit Note Documentation Guide- Visit Note Formats article to choose the best format for your charting preferences.

Next, within certain visit note formats, you can reference new data that you added to the visit note back to the Clinical Profile. For example, the different Complete H&P Notes and the Pre-Op Note all have options for you to export data added to specific sections of the visit note back to the corresponding section in the Clinical Profile.
Export from Visit Note to Clinical Profile & back.png
  • User Tips:
    • If you clicked the "add..." button from a new record in the visit note but you never completed the add form, you will not be able to see the "add..." button again.
    • If you "Import Allergies" and then add new allergies to the Allergies section of the Clinical Profile and import allergies again, you will see duplication. Remove the duplicate data by clicking on the "x" button next to the record in the visit note.


    Lastly, taking certain actions outside of the Clinical Profile can help populate the Clinical Profile such as:
    1. ePrescribing & Ordering Medications
    2. Using Letters & Referrals to share clinical data with other medical professionals outside of Elation
    3. Documenting vaccinations during visit note charting
    4. Filing legal documents to a patient's chart
    5. Addressing Clinical Reminders for Clinical Quality Measures


     

    What information can be referenced into a visit note?

    Any record in the clinical profile can be referenced into a note or visit note to facilitate documentation of a clinical encounter. You can click the "Actions" button next to any header to export the entire section to a note or visit note. You can also click "Actions" next to a specific record to only export that record to a note or visit note. Different records can be referenced into different areas of the visit note depending on what Visit Note Format is being used. Review the various visit note formats in the Visit Note Documentation Guide- Visit Note Formats article to choose the best format for your charting preferences.
    • For certain records, you can also specify how many fields of the visit note you want to reference the data on top of the fields they already belong to. Allergies, drug intolerances, problems and medications can be referenced into the HPI section of all visit note formats. Allergies, drug intolerances and problems can also be referenced into the Review of Systems (ROS) and Assessments sections if available. Problems with ICD codes can be referenced into the Billing Information section to facilitate billing.
     
     

    Frequently Asked Questions (FAQ)

    I spent time updating all the patient’s problems, do I have to rewrite each one in my visit note?

    Document a problem once and never have to retype it again. You can export any item -- or all items -- from each section of the Clinical Profile to your visit note’s HPI, Assessment or Billing sections with just one click. Under “Actions” select “Export”. You can even export synopses from your Clinical Profile to your visit notes.
    Export Options for Problem List.png
     

    Can the problem list be ordered by relevancy not chronologically?

    Yes, you can order your problems any way you like. Reference the Problem List Guide for more information on how to reorganize your problem list.
     

    Can I re-order the different records in each section?

    Yes, any free-text field can be re-ordered. Use the 3 horizontal line button next to the record to drag and reorder the list.
     

    Can I add additional export options for specific records?

    Additional export options cannot be added at this time but you can always copy and paste specific records into different areas of your visit notes.
     

    I clicked "add..." to add a new record from the Visit Note to the Clinical Profile but accidentally clicked "Discard". Now the "add..." button is gone. What happened?

    If you clicked the "add..." button from a new record in the visit note but you never completed the add form, you will not be able to see the "add..." button again. You will need to manually add the record to the relevant section in the Clinical Profile.


     
    Next Step

    Explore the different export and import options to familiarize yourself with Elation's amazing charting shortcuts.


     

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