Daily Note
For Daily Note, by default, there is only 1 tab under the Subjective section. But if the Pain Scale on Daily Notes feature has been turned on, 2 sub-tabs will appear under the Subjective Tab:
- Default
- Pain Scale
Default Tab
Here are all the elements in the Default Tab
- Related Appointment
- Date of Documentation
- Visit start and end time
- Visit #
- Primary Diagnosis
- Encounter Diagnosis
- All of these components are similar to those that are in the Subjective Section for Initial Evaluation, ReEvaluation and Progress Note. Please review the lesson here for more details.
- Comments - Users must enter any new information that has been observed during the visit in this textbox.
- Does the Patient Have a History of Falls - When the YES button has been selected, a text box appears for users to enter more information.
Pain Scale
Here are all the elements in the Pain Scale sub tab
-
Pain Scale
-
Nature and Character of Pain
-
Location of Pain
Discharge Note
For Discharge Note, only 1 tab is available in the Subjective section. Instead of the title Subjective, it will state "Discharge".
It has the same first 4 components from the previous notes types:
- Related Appointment
- Visit start and end time
- Primary Diagnosis
- Encounter Diagnosis
But succeeding areas are specific only for discharge notes.
5. Patient's current functional status - prior to discharging the patient, the clinician must indicate the current functional status
6. Number of visits attended by patient
7. Number of visits missed by patient
8. Does the patient have a history of falls? - When the YES option is clicked, a text box will appear to allow comments
9. Was the patient able to achieve the goals prior to discharge? - If there are any goals indicated in previous documentation, it will appear in the goals section of the discharge note.
If the answer to this question is NO, the second line that will appear will ask "Reason goals were not attained (Barriers to treatment/learning/compliance, etc.)"
If the answer to this question is YES, the second line will ask "Provide details about the goals achieved by the patient (List goals, extent of progress towards the goal, etc.)"
10. Final recommendations from rendering provider - There are 3 options for this question:
- Return to referring provider
- Continue home exercise program
- Additional note
Any option that the user selects, a comment box will appear under the question for additional notes.
11. Do you want to add the physician signature? - Yes and NO option
12. Is the Physician Name Required? - once enabled, it will ask the user to select the physician from the Referral Resource drop-down list
13. Extended Provider Signature once the YES option is selected, it will ask the user to select a clinician from the drop-down list