<< Click to Display Table of Contents >> Navigation:  »No topics above this level« Overview

The Notes application is a documentation tool used by clinicians to capture a patient encounter. This can be accomplished through the use of templates, which can automatically insert data elements into a note, by using data elements alone, or through a  combination of both. When Notes is opened within a patient chart, it is made up of 3 panels: Create Note, Note List and Template Library. The Create Note panel allows the user to create new notes using templates, data filters and formatting tools. The Note List allows the user to view existing signed notes and drafts. The Template Library allows the ability to view, edit or create new templates to be used within the Create Note panel.

 

NOTE: Facilities outside of the United States may choose a date format of MM/DD/YYYY or DD/MM/YYYY to be used on all date fields in the Notes Application. Whichever date format is selected will be reflected in all date fields and column displays throughout the application. A TruBridge Representative should be contacted in order for the date format to be changed.

 

NOTE: HIPAA regulations require that Psychotherapy Notes be kept separate from the rest of the medical record and that only the originator of the document have access to them. The TruBridge EHR is built to be a collaborative tool and therefore does not have the ability to control access specifically to Psychotherapy Notes. For this reason, all Psychotherapy Notes should be stored outside the TruBridge EHR.