• Go to the Advanced Progress Note screen. 
  • Once the clinical evaluation is completed, click on the Save button located at the top of screen. 


  • The following screen will be displayed: 


  • To add a new diagnosis to the patient on the day of the encounter, press the Add Dxs button located at the top of the screen.


  • The following screen will be displayed: 


  • Select new patient diagnosis. Double-click on the diagnosis. Or, select and then press the Save button, located at the top of the screen.


  • In both cases, the following message will be displayed:


  • Press the Yes button to add the new diagnosis to the patient's active diagnoses.
  • Press the No button to cancel the action.
  • The added diagnosis will automatically go to the Todays Dxs section. It will also be displayed in the Billable Problem List section.


  • Note: If the section labeled Encounter Billable Problem List is empty, from the Patient Current Diagnosis section, double click on the diagnosis you wish to add to the Encounter Billable Problem List area.


  • If you wish to add F codes, press the F Codes button, located at the top of the screen.


  • The user can select the Get F Codes option to add the F codes that apply to the patient. Or, the user can select the Hedis F Codes option, with the previously selected codes, according to the clinical evaluation performed on the patient. 


  • You can select more codes according to your criteria or simply press the Save button to save the selected codes.
  • They will automatically be displayed in the Encounter Procedures section.


  • Signatures: If you wish to record the patient's or legal guardian's signature on the progress note, press the Signatures button.


  • Frequent Procedures: If you wish to add frequent procedure codes, press the Frequent Procedures button. (These procedure codes are the ones that are configured in the Staff and Providers / Close PN Codes screen).


  • The following screen will be displayed: 


  • Select the frequent code, which you want to add to the patient's clinical evaluation encounter.


  • Once selected, press the Apply button.


  • Automatically, the selected frequent codes will be displayed in the Encounter Procedures section.


  • If you wish to add any procedures to the meeting, to be used in the invoicing process, press the Add Procedures button.


  • The following screen will be displayed: 


  • Select the procedure code you wish to add to the encounter. Double-click on it or select it and then press the Save button located at the top of the screen.


  • Automatically, the selected procedure code will be displayed in the Encounter Procedures section.


  • If you wish to leave the progress note open, to continue with the clinical evaluation of the patient later, press the Leave Note Open button.


  • You will automatically be taken to the Open Progress Notes section of the Clinical Records screen. (Fill in the Meaningful Use Summary Settings section (If the patient has already registered their Direct account and email address on the Patient Details screen, they will automatically be displayed in that section).


  • To send the clinical summary to the patient to your portal, select the Auto-upload clinical summary for this patient option to comply with the Meaningful Use metric, which requests that the patient be provided with a copy of their clinical data after each encounter.
    • Important Note: The patient must have the email address registered in the Patient Details screen or the Direct account. If the patient has a Direct account on the Patient Details screen, it will appear in the field labeled Direct.
  • To deliver the clinical summary to the patient, select the Print Clinical Summary option to meet the Meaningful Use metric, which requests that a copy of the patient's assessment and clinical data be printed.
  • Fill out the Encounter Procedures section.
  • If you wish to add a procedure code, in the encounter, for use in the billing process, press the Add Procedures button.


  • The procedure code search screen will appear.

  • Perform the search, select the procedure code and press the Select button.

  • The selected procedure will be displayed in the Encounter Procedures section.

  • Verify the Assessment and Plan narrative. If you do not agree with anything in this section, press the Previous button to return to the patient's clinical assessment and make the appropriate modifications.


  • Use Default Codes: Initial Visit or Follow-up Visit. Just press the buttons on the right side of the screen. If you wish to use the Default codes, select the checkbox at the top of the section, called Use Default Codes.


  • Close Progress Note: Once you have completed the clinical evaluation of the patient, select the Save and Close button.


  • The following confirmation message will be displayed:


  • Press the Yes button to close the progress note.
  • Press the No button to cancel the action.
  • When the progress note is closed, it cannot be edited, only Addendum/ Amendments can be added (recommended option for uploading Meaningful Use measurements).

Note: In order to close the progress note, it is required to select a procedure in the Encounter Procedures section and a diagnosis in the Encounter Billable Problem List section.



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