Note: Uploaded clinical notes are identified by 
. Selecting an uploaded clinical note opens the note in the program in which it was created.
The information that appears in the list of all clinical notes page for a patient varies depending upon file type (electronic, uploaded, or Care360 EHR encounter) and the actual information that is entered for a clinical note. In addition to the timestamp, the following information describes, by file type, how displayed sections are labeled:
• For encounter notes finalized and signed after January 2017:
• If a user manually typed in a name for the encounter note, then this name appears.
• If an encounter note was not manually given a free text name, then the default naming convention (Reason for Visit, Chief Complaint, or Diagnosis) appears.
• If neither of the above are available, then Encounter Note and the date the note was last edited appear.
• For encounter notes finalized and signed before January 2017:
• If available, chief complaint appears (if more than one, the most recent chief complaint displays).
• If available, the diagnosis appears (if more than one, each diagnosis is listed and separated by commas). If the diagnosis is unavailable, one of the following items appears (if an item is unavailable, the next item in the list is used):
• Reason for visit
• The first 72 characters of the last Subjective, Objective, Assessment, or Plan text that was edited
• The last set of vitals data entered for this note
• Review of systems information
• Physical exam data
• Additional comments
• Procedure data
If none of these are available, then SOAP Note and the date the note was last edited appear.
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Note: Notes that are marked Erroneous can be also be viewed from the list of all clinical notes for a patient if you select the Show Erroneous check box. The information that displays for erroneous encounter notes is determined in the same manner as a finalized note. |
• For uploaded clinical notes, the reason for visit appears, if available. If reason for visit is not available, then the name entered by the user uploading the document appears. If neither of these are available, then the file name of the uploaded file appears.
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Note: Uploaded clinical notes are identified by |
• For electronic clinical notes, a description of the service appears. If the description of service is not available, a unique document ID appears (for example, an order number or accession number).
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Notes: • If a clinical or encounter note is marked with • While viewing all clinical notes for a patient, you have the option of changing the document type of electronically received transcribed or textual clinical notes. For more information, see Change the Document Type. |
or 
, then associated billing details are available for the note. For more information, see 
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