There are several options for documenting a procedure. 


Option #1

  • Go to the Advanced Progress Note screen.
  • Press the Procedures button, located in the Side Bar section.


  • Or, click on the Search button located at the top left of the screen and select the Procedures option.
  • The following screen will be displayed:


  • Press the Add button, located at the top of the screen. 


  • The following screen will be displayed:
    • Note: You can also search by code or description from the search area.
  • Select the procedure you wish to perform on the patient. Once selected, press the Save button, located at the top of the screen.
  • Or, double click on the selected procedure.


  • Write a note in the Procedure Note field.


  • Type a text, in the Template Text field.


  • Or, press the Load Template button to select a Template related to the procedure.


  • The Template will be automatically displayed.


  • Press the Select button, located at the top of the screen.


  • The following screen will be displayed:


  • Press the Replace keywords and close button to replace all keywords and close the screen. 


  • Automatically, the selected Template will be displayed in the Template Text section.


  • Then, press the Save button, located at the top of the screen, to add the procedure to the progress note.


  • The following confirmation message will be displayed: 


  • Press the Yes button to include the selected procedure code in the encounter claim.
  • Press the No button to cancel the action.
  • Select the procedure date and facility.
  • Press this button to search for a Template to include in the documentation of the selected procedure.
  • Press this button to edit the selected Template.
  • Press this button to change the selected procedure code.
  • Press the Save button to save the procedure.


Option #2

  • Go to the Advanced Progress Note screen.
  • Click on the Procedures link in the Clinical Evaluation section, or click on the Add button located in the Clinical Evaluation section. Or, click on the Add button located in the Clinical Evaluation section (It must be configured in the Progress Notes Templates Settings screen).   


  • The following screen will be displayed:


  • Press the Add button, located at the top of the screen. 


  • The following screen will be displayed:
    • Note: You can also search by code or description from the search area.
  • Select the procedure you wish to perform on the patient. Once selected, press the Save button, located at the top of the screen.
  • Or, double click on the selected procedure.


  • Write a note in the Procedure Note field.


  • Type a text, in the Template Text field.


  • Or, press the Load Template button to select a Template related to the procedure.


  • The Template will be automatically displayed.


  • Press the Select button, located at the top of the screen.


  • The following screen will be displayed:


  • Press the Replace keywords and close button to replace all keywords and close the screen. 


  • Automatically, the selected Template will be displayed in the Template Text section.


  • Then, press the Save button, located at the top of the screen, to add the procedure to the progress note.


  • The following confirmation message will be displayed: 


  • Press the Yes button to include the selected procedure code in the encounter claim.
  • Press the No button to cancel the action.
  • Select the procedure date and facility.
  • Press this button to search for a Template to include in the documentation of the selected procedure.
  • Press this button to edit the selected Template.
  • Press this button to change the selected procedure code.
  • Press the Save button to save the procedure.



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