<< Click to Display Table of Contents >> Navigation:  Scheduling Block > Group Task > Individual Note

Within the Group Detail screen, select Individual Note to add documentation to a selected patient account on the screen. An Individual Note may only be added if the patient's appointment has been linked to a visit.

 

If a Documentation document has been preloaded in the Individual Note field in the Tasks/Procedures table for the group task, once Individual Note is selected, the preloaded template will automatically display in the Pending Documents section of the Document List screen. If not wanting to use the preloaded Documentation document, select the document and then select Remove from the action bar. Another document may be selected from the Search Documents section of the screen to use for the Individual Note. If a document has not been preloaded, the Document List will display and another document may be selected to use.

 

Once the desired document has been selected and displays in the Pending Documents column, select Process on the action bar. TruBridge EHR will then display the document on the screen to be completed. To pull in the Group Note, one of two options may be followed:

•Select the Group Note section preference, the Group Note Selection screen will display to select the Group Note. Once selected, select Insert on the action bar and continue documentation. For section preference setup, please see the Documentation Setup user guide.

•If a section preference is not set up, Group Note may be inserted via Charting Options. For more information regarding Charting Options, please see the Documentation Functionality user guide.

 

Once documentation is complete, select Update on the action bar. TruBridge EHR will then display the information that was documented on the ClinDoc template.

 

Once all information has been documented, select the back arrow on the action bar. The information will then be saved and further editing of the Individual Note may be done at any time, if needed. If the Individual Note is no longer needed, select Retract on the action bar. To exit the Individual Note, select the back arrow to return to the Group Detail screen.

 

The status of the Individual Note will display on the Group Detail screen in the Documentation Status column. The status' are as follows:

•Not Started: The user has not started the Individual Note.

•Unsigned: The user has started the Individual Note, but has not signed.

•Signed: The user has signed and is finished with documentation.

 

For more information about Documentation documents, please refer to the Documentation Functionality and Documentation Setup user guide.