Writing Clinical Notes

Commure Pro Mobile NoteWriter™ may be available on your Apple® device, if your organization has implemented this feature, and if you have been granted access to it. When Mobile NoteWriter is enabled, additional functionality is available in the Clinical Notes module and providers can use it to write, edit, and submit physician documentation. Mobile NoteWriter is designed to integrate fully with Commure Pro’s other modules, including:

• Clinical results modules: Providers can leverage all of the data from the clinical modules, such as Allergies or Lab Results, copy this data to their note (either before or after creating a note), and continue to edit and update this data as necessary.
• Charges module: If NoteWriter has been configured to work with the Charges module, you can enter charges for each of your patient visits.
• CPOE Orders module: If NoteWriter has been configured to work with the CPOE Orders module, you can also enter orders for each of your patient visits.

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Launching the Mobile NoteWriter Application

There are several ways to access the NoteWriter application.

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Access Mobile NoteWriter via the Clinical Notes Module

NoteWriter opens directly from the Clinical Notes module. You would typically use this approach when you want to review the patient’s prior clinical notes before creating a new clinical note for that patient, or deleting, or editing a draft note. To launch NoteWriter via Clinical Notes:

1. Select a patient from the Patient List and then select the Clinical Notes module. The Clinical Notes summary is displayed.

You have the chance to review all of the patient’s notes on file in the Clinical Notes module before adding a new note. For more info on this, seen Clinical Notes module.

2. Tap Add in the top-right corner of the screen to start a new note. NoteWriter opens displaying the patient information at the top, with options for selecting the visit, note date, and specialty information.

From here you can start a new note or manage an existing draft you have saved.

• For information on starting a new note, see Starting a New Note for a Patient.
• For information on editing a draft, see Managing Draft Notes.
• For information on entering data in a note, see Entering Data in a Note.

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Access via the Pending Button

Use this method to quickly access a list of all your draft notes for all of your patients. You can then edit or delete any of the draft notes in your list using the NoteWriter Wizard, which lets you edit a draft note but does not include functionality for creating new notes. For detailed instructions, see Managing Draft Notes.

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Access via the Swipe Action in the Patient List Module

You can quickly access Mobile NoteWriter for a patient in your Patient List. You would typically use this approach when you want quick access to writing a clinical note and do not feel it is necessary to first review the patient’s previous clinical notes. The options that display in the patient visit row after a swipe action are customizable. For details on how to change these options, see Configuring Swipe Options for the Patient List.

1. In the Patient List module, identify the specific patient visit for which you want to start a new clinical note.
2. Swipe right-to-left on that patient visit row.
3. When the context buttons appear, select the Add Note button (if available), or select the More button and then select Add Note from the menu. NoteWriter opens displaying the patient information at the top, with options for selecting the visit, note date, and specialty information.

From here you can start a new note or manage an existing draft you have saved.

• For information on starting a new note, see Starting a New Note for a Patient.
• For information on editing a draft, see Managing Draft Notes.
• For information on entering data in a note, see Entering Data in a Note.

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NoteWriter Screen at a Glance

At the top of the NoteWriter screen is a Patient Header, which displays the patient’s name, demographic information, and MRN. You can also choose the patient visit, note date, and specialty in the Patient Header. The Patient Header is hidden as you navigate the different sections of the note, but you can always access this information. To display the Patient Header:

• Tap the Patient Information icon at the top of the screen.

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Selecting Visit and Note Date

Most of the time, the currently selected visit is the one a provider will write a note for. However, the current visit on the patient list may not be the one that the physician wants to document. Providers can switch to a different visit if there are additional visits available for the patient. Since providers are writing notes for different purposes on visits and each visit needs a “standard” note type (H&P, Progress Note, Discharge Summary), the note templates that are available may vary depending on the visit that is selected, as your Administrator may have configured specific notes for specific visit types. Systems may be configured to check visit times to avoid conflict with visits that are close together. If this close-by visit check is enabled for your site, you may see an indication when selecting a visit that it is close to another visit. This is to help ensure that the correct patient visit is selected for the note. You can also specify a date and time for your note, although you will probably use the default settings (current date and time) most frequently, such as for active inpatient or outpatient visits, or on the discharge date. To select a visit or note date:

1. In the Patient Header at the top of the screen, tap to expand the Visit and Note Date list.
2. Select the visit you want to write a note for, and select the note date and time.
3. Tap Close to collapse the list.

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Assigning a Specialty to Your Note

If your administrator has configured your system enabling you to designate a specialty for your note, you can select from any of the specialties that are available to you. The Specialty menu provides a list of the specialties that are configured for your specific area(s) of expertise. Depending on how your administrator has configured your system, you might need to select a specialty before you can sign and submit your note. If your administrator configures your account with a default specialty, this default specialty is used each time you create a note, but you can change this to any of your other associated specialties. If the list of specialties available to you is incomplete or needs to be updated in any way, contact your administrator. Assigning a Specialty to your notes can help you to locate a specific note, especially after you enter several notes and your list of notes starts to grow on the Clinical Notes pane. The Specialty that you select during note entry displays under the associated note type in your list of clinical notes. Upon printing (or previewing) the note, the Specialty that you have selected displays in the note header, below the information used to identify the note type. To select a Specialty:

• In the Patient Header at the top of the screen, tap to expand the Specialty list and then select a specialty.

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Changing the Note Type

If a note template has been configured to allow it to be reclassified, then the Note Type option is available. You can choose from the available note types that have been made available by your Administrator to reclassify a note from its original type. To change a Note Type:

• Tap to expand the Note Type list and then select the note type you want.

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Note Templates List

Note templates provide the framework for adding your clinical documentation. The NoteWriter application provides note templates that can be used or customized for departments or other groups to accommodate a particular workflow or clinical situation that is shared among a group of providers. Templates can also be customized for individual use, so that providers with a specialized focus can choose a template with the correct level of detail for a particular clinical setting. The NoteWriter application provides the following basic templates that you can work with to enter all of your clinical documentation:

• History and Physical Note
• Progress Note
• Chart Notation
• Operative Note
• Consult Note

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Draft Notes List

If you have saved a note for later, it is listed in the Draft Notes section in NoteWriter. You can edit draft notes from this screen or from the Clinical Notes summary list. If you have a draft note saved, the Draft Notes section is displayed by default when you open NoteWriter.

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Starting a New Note for a Patient

Each time that you start a note for a patient who does not have any draft notes in-progress, you are prompted to select from a list of note templates. Only note types that are relevant to the visit type for which you are writing a note are available. Before selecting a template, you must first select a patient visit (unless an administrator has configured your system for auto-selection of the currently-selected visit). The templates displayed on your list may change as you select different patient visits, since templates are specific to visit type. Once you select your visit, all of the templates associated with that visit type are displayed in a searchable hierarchy, and you can select the template you want. View a Quick Reference on Starting a New Note To start a new note:

1. Select a patient from the Patient List and then select the Clinical Notes module. The Clinical Notes summary is displayed.
2. Tap Add in the top-right corner to start a new note. NoteWriter opens displaying the patient information at the top, with options for selecting the visit, note date, and specialty information.
3. Review the information in the Patient Header at the top of the screen to confirm that all of the selections are correct, including: Patient, Visit, Note Date, and Specialty.
4. In the Write a Note section, select the type of note that you want to write.
   • If your administrator has enabled a single template for your department, your note displays automatically and you can begin to enter data into the note.
   • If your administrator has enabled multiple templates for your department, you are prompted to select your template from a list of available templates. To search for a particular template, start typing in the Search Templates text field. The list of note templates is filtered to match the text that you enter.

From here you can begin entering data in your note, and then sign and submit, or save it as a draft and continue later.

• For information on entering data, see Entering Data in a Note.
• For information on saving a draft, see Saving a Note as Draft.

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Customizing your Note Templates List

The list of note types available to you when you enter mobile NoteWriter may include some notes that you use more frequently than others. In this case you can customize your notes list to change the sort order so your most frequently used templates appear at the top, and even hide note templates you don’t want to see. To customize your note templates list:

1. In the Write A Note section, tap Customize. The Note Type List Customization options display.
2. Customize your notes list using the following options:

• Tap the Show/Hide icon to include a note as Visible or exclude it as Hidden.

• Tap a note template in the list that you want to move so that the Sort handle displays and then drag-and-drop it to a new position in the list.

3. Tap Save at the bottom of the list to save your changes. Tapping Cancel or Close will discard any changes and close the Customization options.

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Entering Data in a Note

The ways that you enter data into a note depend on the type of template that you are using and the type of data you are entering. This may include a combination of entering free text, selecting checkboxes or radio buttons (for example, ROS/Exam), or selecting items from a list (for example, Problems). The Progress Note note template provided by Commure Pro using SOAP includes examples of each of these methods. View a Quick Reference on Entering Data in a Note To enter data in a note:

1. Start a note or open a draft note (for details, see Starting a New Note for a Patient or Managing Draft Notes).
2. Begin to enter data in the note. The sections of a note are expandable/collapsible. To open a different section of the note template, tap the section name to expand or collapse the section.

Different note templates include different sections and components, such as checkboxes, list menus, text fields, buttons, and even links to other modules (such as Charges, Orders, and other clinical results).

• Adding Data to a Note from a Clinical Results Module
• Entering Data as Free Text
• Entering Data into Body System Checklists
• Including Charges Data in a Note
• Including Orders Data in a Note

3. After you’ve entered data into your note template, you may be ready to sign and submit your note, or you may want to save it as a draft so you can more additional edits later. Choose one of the following options for completing your work on the note.
   • Tap Save to save the note as a draft. For more information about working with drafts, see Saving a Note as Draft.
   • Tap Submit to sign and submit the note. For more information, see Signing Clinical Notes.
   • Tap Share to share a draft with another provider. For more information, see Sharing Draft Notes.

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Adding Data to a Note from a Clinical Results Module

NoteWriter is designed so that providers can leverage existing data from other modules in the Commure Pro app to link data to your note either while reviewing clinical results before you start a note (known as Preselection), or after you start a note by copying clinical results into your note from other modules in the app. The data you can link/copy varies by module. It is available for the following modules: Allergies, Clinical Notes, Medications, Lab Results, Orders (non-CPOE Orders), Test Results, and Vitals Signs. Below is a summary of data you can select in each module:

• Allergies: You can preselect one or more allergies in the Summary list to be included in your new note.
• Clinical Notes: You can preselect one or more notes from the Summary list. You can also select a note and then highlight specific text from within the note to include in your new note. Details for this are described in Including Text from a Clinical Note or Test Result. Note that draft notes cannot be preselected.
• Medications: You can preselect one or more medication from the Summary list on the Medications tab.
• Lab Results: You can preselect a row from the Summary list to include all of the data for the result. You can also select a result and then preselect one or more components from Table view.
• Orders (non-CPOE orders): You can preselect one or more order in the Summary list to be included in your new note.
• Test Results: You can preselect one or more notes from the Summary list. You can also select a note and then select specific text from within the note to include in your new note. Details for this are described in Including Text from a Clinical Note or Test Result.
• Vital Signs: You can preselect a row from the Summary list to include all of the data for the vital. You can also select a reading/value from one of the previous time frames and then preselect a result from Detail view.

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Preselecting Clinical Data Before Starting a Note

NoteWriter’s preselection functionality lets you choose the clinical data you want to document prior to starting a note. This is typically a pre-rounding scenario where you identify results in the clinical modules that you want to include in your note, and then when you do start the clinical note, the data you’ve selected is populated automatically. You can pre-select clinical data on both your Apple device and on the Commure Pro web application. Any data that is pre-selected on one platform also shows as pre-selected on the other. As a result, a provider can pre-select data on their Apple device (for example), and it will be added to notes that the clinician creates on the web application, or vice versa. Pre-selection must be enabled on your device via Settings > General, and set Show Preselection to ON. For more information, see Enabling or Disabling Pre-Selection of Clinical Data for Mobile NoteWriter. To preselect clinical results to be included in a note:

1. Select a patient from the Patient List and then select the clinical module that you want view.
2. Tap Preselection next to each result you want to preselect for a note.

To select all of the results in the list, tap the Select All radio button at the top. When you start a note for the patient, the clinical results you’ve selected are automatically populated in the sections where clinical data is displayed. For example, in a Progress Note the Data section includes clinical results; in a History and Physical note, the Diagnostics section includes clinical results.

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Linking Clinical Data While in a Note

You can incorporate clinical data from other modules in Commure Pro into your note template even after you start the note. This is called linking clinical data in a note. Typically, when you click a link in your note template to navigate to another module, you use checkboxes to select the items you want to copy over from that particular module. Once you select the items you want to include, you can copy these items to your note with a single click, and you are returned to your note template, where you can select data from additional modules or navigate elsewhere. You can continue to add, remove, and modify clinical data in the note template until you sign a note; once you sign a note, it becomes final and you can no longer make edits to it. To link clinical results to a note:

1. Navigate to the section of your note where the clinical data module links reside, and then select one of the clinical data module names within the note. The clinical module opens where you are prompted to select from any results that pertain to your selected patient.

For example, in a Progress Note template, tap the Data tab.

2. In the module summary screen, tap Selection next to each result you want to copy to the note.

To select all of the results in the list, tap the Select All radio button at the top.

3. Tap Copy to Note in the top-right corner of the screen. You are returned to the section of your note where you chose to link the data. The name of the clinical module displays with the reference to the clinical data you selected,

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Including Text from a Clinical Note or Test Result

You may encounter situations in which you want to reference only selected blocks of text in a clinical note or test result. You can easily copy over any sections, paragraphs, or words from a note or result to include within your note. These fragments are included in the body of your note, identified by a reference to their source clinical note or test result. To preselect text from a clinical note or test result:

1. Open the Clinical Notes or Test Results module from which you want to copy data and select an item from the summary list.
2. Double-tap the text to display the text grab points and edit menu, and then drag the grab points to highlight the text that you want to copy.
3. In the edit menu, select Preselect Text (you may need to tap the arrow in the menu to see more options). You can also tap Preselect All Text to select the entire note or result.

When text has been preselected, you can tap Preselected Text near the top of the screen to see all of the text from the current note or result that you’ve selected for a note.

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To delete preselected text from a clinical note or test result

1. Open the Clinical Notes or Test Results module where you have preselected text for a note.
2. Select the item from the summary list that is preselected.
3. At the top of the screen, tap Preselected Text to see all of the text from the current note or result that you’ve selected for a note.

4. Tap Delete to clear all of the preselected text for that note or result.

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Adding Annotations to Clinical Data

After you copy clinical data from another module into your note template, you may discover the need to provide additional notation in your note template to supplement this data. In such cases, you can add annotations to all clinical data that you copy into your note. Use annotations to remind yourself to follow-up on a particular lab test or other test result. Or, annotate clinical data to provide background information on a particular section of a note, so that you can consolidate content from other clinical notes or results and restrict the duplication of content across multiple note instances. All text that you include in your annotations displays in your note only; this text is not added to the original clinical data that you copied over from one or more of the Commure Pro modules. As with all other data added to your note, your annotations are visible only to you while your note remains in draft status. Once you sign your note and it is added to the Clinical Notes list, your annotations are visible to all users in your department, just like the other content in the note. To annotate clinical data copied over from another module:

1. Navigate to the section of your note template where the clinical data module links reside.
2. Tap Annotate next to the data for which you’d like to add comments.

3. Tap into the empty text field that displays and then type the annotation you’d like to add. You may have the option to use Quick Text entries for this field. If Quick Text entry is enabled and you wish to use it, see Inserting Quick Text for more information on using it.

4. Tap Done to close the keyboard. Once you sign your note or save it in draft form, your annotation displays with its associated clinical data when you print the note.

To see how your annotation will look once our note is finalized, you can click Print Preview to see a view of the note in preview mode.

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Entering Data as Free Text

Free text fields enable you to type or dictate (using your device’s speech-to-text capabilities) data directly into NoteWriter. You can use free text fields to enter descriptive data about a patient whenever the other data entry options are inadequate for providing the level of detail you want. Once a note is signed, previewed, or printed, free text data displays as paragraph blocks in a note. Templates can employ free text fields in many ways. They can appear in any section of a template, and they can serve a variety of purposes. In some cases, free text fields are simple and direct; in these cases, you are required to enter descriptive data. The text box for a Patient Narrative is one example of a simple free text field. Note that even though these fields are “simple,” you can typically use Quick Text in conjunction with many types of free text fields to automate the redundant aspects of text entry without sacrificing the freedom that it provides. Templates may also include free text fields to gather data, such as statistics and other metrics from examinations. For example, free text fields might be provided for you to enter findings, such as in the Exam section of the default SOAP note template. When it is available from its corresponding clinical data module, this data is automatically populated in the correct fields. You can edit the data in any of these fields, but note that any changes made to this data are saved with the note instance only; these changes are not propagated back to the clinical data module. Free text fields can also be provided as part of other data entry methods. For example, free text fields can be used in conjunction with a body systems checklist to enable you to add and edit existing information until you get the desired level of specificity you want. In such cases, the true power of NoteWriter is revealed, as these hybrid methods provide the convenience of automation without forcing you to sacrifice any of the freedoms available to you in ordinary free text entry.

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Inserting Quick Text

Quick Text enables providers to simplify the entry of frequently-used phrases, terms, and longer standardized text such as a typical surgical procedure. Use of Quick Text entries can save time by eliminating redundancy that can occur when you enter notes for commonly-encountered clinical situations. If your department administrator has defined a set of Quick Text entries for your use, then you can begin using this feature at any time. Otherwise, you must first define Quick Text for your own use. For more information, see Managing Quick Text Entry. To insert Quick Text into a text field:

1. Tap Quick Text to open the Insert Quick Text pop-up.

2. (Optional) If Quick Text is organized into categories, tap to expand the category or subcategory you want to view. 3. Tap to select the Quick Text entry or entries that you want to enter into the text field. You can sort the Quick Text entries from A-Z or from Z-A by tapping the Sort.

4. Tap Close to close the Insert Quick Text pop-up.

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Using Shortcuts to Insert Quick Text

If you have shortcuts defined for your Quick Text entries, you can use them to quickly insert your Quick Text entries as follows:

1. Tap into the field where you want the Quick Text entry to be inserted.
2. Type the shortcut for your Quick Text, and then press the space bar on your keyboard. The Quick Text entry displays in the text field.

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Carrying Forward Data Using Insert Previous

As with Quick Text entries, the Insert Previous feature helps to eliminate redundancy in data entry. This feature enables providers to carry forward data from an earlier note and revise this data as needed to document subsequent visits for a particular patient. As a result, you can restrict entry of new data so that you only need to document the incremental changes in a patient’s status without needing to re-enter this data from scratch on subsequent visits. Note that your System Administrator has configured the fields were this is enabled. When you use the Insert Previous feature to access previous notes for a particular patient, you can restrict your search scope to include only your own notes. When you access previous notes in this way, you are given access to all of your recent notes, regardless of whether they exist in draft form or as completed notes. You can also widen the scope of your note access to include all notes belonging to your department. In this case, you are given access to all completed notes that have been signed by providers in your department in addition to your own signed and draft notes. To carry forward data using Insert Previous:

1. Tap Insert Previous that displays above any data field in your template that supports this feature.

The Insert from Previous Notes window displays.

2. Select which types of notes you want choose from:
   • My Notes: To display your own most recent draft or signed notes.
   • My Department’s Notes: To display your most recent draft or signed notes, along with recent signed notes that were authored by colleagues in your department.
3. Select the data of the entry that you want to carry forward.
4. Tap Insert Selected. The selected data of the previous entry is inserted into the current field. If necessary, you can modify text from this entry to suit the current note.

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Entering Data into Body System Checklists

If your template supports it, you can enter all data from your review of systems or exam into body systems checklists. This method of entering data can improve your efficiency, since it enables you to enter pre-defined descriptions for all standard (normal) results from the history and physical. As a result, you can often enter data for a body system with a single tap, and focus on the noteworthy areas of the history and physical, which are the abnormal results. The body systems checklist may be included in different areas of a template; the type of data that you enter into it may relate to a particular phase in your workflow, as represented by where the checklist appears in your template. When you sign and print a note, only the body systems that you select from a checklist are included in your signed and printed note. To make the formatting of all signed and printed notes consistent, these systems are organized in a particular, uniform order. No matter what order you use to enter this data, it is organized in all printed notes (including print preview mode) in a standardized way. To complete a body systems checklist:

• Tap Normal to indicate a body system appears normally. The standard, pre-defined text describing normal results are filled in automatically, including any Quick Text entries that were entered in this field. You can modify the text for any body system as you complete your note, including the pre-defined text entries (defined in your template) that are added for normal body system results.
• Tap Abnormal to indicate any findings for a body system. A blank text field displays so that you can enter specific data for the component, since pre-defined terms cannot be used for abnormal results.

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Entering Review of Systems (ROS) Data

In an ROS section of a template, a body systems checklist can be used for data from a review of systems. If your template includes a body systems checklist as part of the subjective phase of a SOAP progress note, you can enter the data from your subjective assessment of each patient using the ROS checklist. The display of ROS lists is configurable. For more information, see Customizing Note Entry.

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Entering Exam Data

A body systems checklist is used in the Exam section of a template to enter all of the data from a patient’s physical exam. This checklist is similar to the one provided in the Subjective and ROS sections; however, the pre-defined text corresponding to the body systems in this checklist is specific to exam results. Note that you can delete Vitals and I/O data from a note with a single click of the trash cans associated with each type of data. This can help to free up additional space for adding affirmations and/or other updates to the progress note.

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Entering Diagnosis Codes

Some note template sections may include an option to Search For Problems, which opens a Diagnosis Picker for selecting diagnosis codes in your note. There are several ways that you can quickly select the appropriate diagnosis codes:

• Select it from one or more lists: You can select diagnosis codes from a variety of list options. Each of these list options contains a different set of codes, such as your personal favorites (Favorite Diagnoses), commonly used codes from your department (Pickers), or diagnosis codes from the patient’s history (Existing Problems). See Selecting Diagnoses from Lists (Favorites, Existing, Latest Used, or Pickers).
• Search for it: If you cannot find the code you want using one of the options above, you can search for it from the master diagnosis list. See Selecting Diagnoses Using the Search Option.
• Enter it as free text: If you cannot find the code you want using the options above, you may be able to enter a diagnosis as free text. See Entering Diagnoses as Free Text.
• Provide a plan in response to your problem list: If your template supports it, you can enter all assessment and plan data from patient visits into your note templates. See Entering an Assessment and Plan in Response to the Problem.

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Entering an Assessment and Plan in Response to the Problem

If your template supports it, you can enter your plan for responding to all assessments on your patient’s problem list. In the default progress note templates provided with NoteWriter, an empty text field is provided for this purpose, which is located at the bottom of the A/P note template section. As with all empty text fields in a note template, you can use Quick Text entries to simplify data entry in the plan text field. To promote accuracy and consistency for documentation related to high-risk diseases and problems, some diagnoses may require Assessment and Plan information. If you have selected a diagnosis that is configured as high-risk, the Assessment and Plan field becomes required (*) and the Quick Text list pop-up displays automatically to indicate that you must provide an entry in the Assessment and Plan field. Diagnoses that are classified as high-risk are configured by your System Administrator and require Assessment and Plan information in order to save the note.

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Including Charges Data in a Note

If your administrator has configured NoteWriter to work with the Commure Pro Charge Capture application, you can also enter charges for each of your patient visits. This module can be integrated so that you enter charges as part of your NoteWriter workflow. When implemented, an Add Charge section is present on the note template. You can access the Add Charge section of the template and enter any type of charge, for any type of visit. Once you have entered the Charge Screen, a charge is pre-started for you. If you decide you do not want to continue the charge, tap Delete Charge at the bottom of the screen and go back to your note to Sign/Submit. Your administrator may have also configured the optional E & M Charge Validation feature to help facilitate the entry of E & M charge codes for subsequent hospital care (CPT codes 99231, 99232, and 99233) or for initial hospital care (CPT codes 99221, 99222, and 99223). When this feature is enabled, a View Charge Validation button is included in your template (Progress Note if subsequent care, H & P template if initial care). This feature evaluates whether the information that you have documented in your template is sufficient to support the entry of any of the three levels of charge codes. If your administrator has enabled this feature, keep in mind that it can only be used when completing a Progress Note for subsequent hospital care or an H & P template for initial hospital care.

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Entering Charges Using the Add Charge Section

You can use the Add Charge section to enter any type of charge, for any type of visit. The Add Charge section is typically configured as the last section of the note template.

1. Tap to expand the Add Charge section of your note. The Charge Transaction screen opens.

Some of the data on this screen may already be completed:

• In Diagnoses section near the top of the screen, any problems that you entered on the A/P (Assessment & Plan) portion of your note, or that were used on the patient’s last charge transaction, may be automatically entered for you (this depends on your user preference settings, see Configuring Charge Capture Settings for a User).
• In the Details section, some or all of the fields may be automatically populated.

2. At the top of the screen, tap Add Charges to select the charge(s) that are appropriate for the patient. You can use any of the available methods for charge entry in Charge Capture, such as Searching for charges or diagnoses, or selecting from the patient’s Existing list (for diagnoses), or selecting from the Favorites or Department categories.

A Diagnosis may be added automatically if one is associated with the charge and if your user is setup to do this.

3. In the Details section, enter details for the note and complete any required fields.
4. Tap Submit in the top-right corner of the screen. You are returned to the NoteWriter screen.

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Including Orders Data in a Note

If your administrator has configured NoteWriter to work with the Commure Pro Computerized Physician Order Entry (CPOE) application, you can also enter orders for each of your eligible patient visits. When CPOE is implemented, an Enter Orders tab displays as part of the note template. You can access the order entry section of the template and enter orders from within the NoteWriter template just as you would enter orders directly from the CPOE application. From the Enter Orders tab, users can enter orders as part of their NoteWriter work flow, without needing to navigate outside of the NoteWriter template to access the CPOE application. Note that the rules for selecting the default visit are determined by the CPOE application and not by the rules that normally govern default visit selection in NoteWriter. To enter orders in a note:

• Tap to expand the Enter Orders section to open the Orders module. For information about entering orders in the Orders module, see Entering Orders.

After you Sign & Submit orders, you are returned to the NoteWriter screen.

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Customizing Note Entry

You can customize the display of ROS and Exam entries for a note type by choosing whether to hide entries you do not want to see in the display. To customize entries for ROS and Exam sections:

1. At the top of the NoteWriter screen, tap More.

The Note Entry Template Settings pop-up displays for the note template. You can select from the lists of ROS and Exam entries, with the option to hide them for Note Entry, or exclude the entry from Insert Previous functionality.

2. Select the entries you want to keep and deselect those you wan to hide. When an entry is deselected for Note Entry, then Insert Previous is also disabled.
3. Tap Save to save your selections.

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Managing Draft Notes

NoteWriter is designed with flexibility in mind, meaning that once you start a note and begin entering your patient data, you can save your note in draft form at any time. Auto-save may also initiate if you are in a note long enough, if you exit the note without saving, or if your device times out before you have a chance to save a draft. This lets you create and maintain notes in a variety of situations and clinical settings. Notes in draft form are visible to their author only; other providers in your department or institution do not see your notes displayed on their Clinical Notes list until you sign them. You can access draft notes from within your Clinical Notes module, or from your Inbox, where a list of all drafts is available.

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Accessing Draft Notes via the Pending Button

You would typically use this approach when you want to see a list of all your draft notes so that you can quickly work through them and complete them (as opposed to viewing notes for an individual patient at a time). If you have previously created one or more draft clinical notes for your patients, then the Pending button (located in the bottom tool bar of the application) will have a red badge with a number, as in this example: . This number indicates the total number of your draft notes, unfinished orders, and unsigned documents. Draft notes are available in the Inbox, in their own list under the Notes category. The number next to Drafts list label indicates the number of draft notes that you have created on this or any other mobile device, or on the NoteWriter web application. When you select the Drafts (n) list, all of your draft notes are displayed, thereby providing easy access to all the drafts you have written, without your having to remember which specific patients had draft notes. From this list, you can then quickly access the options to edit or delete the draft notes.

1. Tap Pending in the bottom toolbar and then select Inbox.
2. Tap the List menu button and select Drafts to view the list of draft notes. The Drafts list displays all of your draft notes.
3. (Optional) Sort the list of draft notes by tapping one of the headings.
4. Identify the draft document that you wish to review, and then tap anywhere in that item’s row. The details of that item are displayed.
5. Tap Edit/Sign.

The note opens in the NoteWriter Wizard, where you can make edits to the note, and then sign/submit the note, or save it as draft again. See Electronically Signing Documents and Orders for more information on working with draft documents in the Inbox.

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Saving a Note as Draft

To exit NoteWriter without signing and submitting a note, you can save the note as a draft and continue working on it at a later time. If you exit NoteWriter without saving a note as a draft, any input you’ve added to the note or changes you’ve made will be lost; tapping Done or Cancel does not save your note as a draft. To save a note as draft:

1. Tap Save at the bottom the note template.
2. Tap Yes in the confirmation pop-up that displays to save the note in draft form. NoteWriter closes and the note is saved in the Clinical Notes summary list. Draft notes appear in the list with Draft in front of their name, and with a status of Draft.

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Continuing or Editing a Draft Note

You can edit data in a note at any time, provided you are the author of the note, the note is in draft status, and the note was created using the Commure Pro NoteWriter application. You can always edit the following data in draft notes, regardless of how your administrator configures your application:

• Patient visit: All patient visits are displayed in a drop-down. When you select a different patient visit, all default visit-related template fields update automatically. Fields in which you have specified a different value are left as-is.
• Note date and time: Note date and time are editable fields in the note, depending on the timeframe of the visit.
• Template data: Template data varies by institution, but this data may include text descriptions of a patient’s condition or status, ROS data, clinical data, such as lab and test data, duration of a visit, and data related to billing.

A list of all notes in Draft status is available via Inbox, provided Inbox functionality is enabled for your user. For more information, see Accessing Draft Notes via the Pending Button. To edit a note from the Clinical Notes list:

1. Select a patient from the Patient List and then select the Clinical Notes module. The Clinical Notes summary is displayed.
2. Open a draft note using one of the following methods:
   • Swipe from right-to-left and tap the Edit button that appears.
   • Select a draft note from the list (prefixed with Draft and with a status of Draft). The Details screen opens and displays the text for that note. The top of the screen contains a heading with fields for Note Type, Date, and Status. An Edit icon is available next to the Draft status to open the note for editing. Below the heading is the body of the note with the input you’ve entered into the note template.
3. Tap Edit next to the Draft status to open the note template for editing. The template opens in NoteWriter.
4. Make the changes you want and then Save, Share, or Submit the note.
   • For information on entering data in a note, see Entering Data in a Note.
   • For information on saving a draft, see Saving a Note as Draft.
   • For information on sharing a draft, see Sharing Draft Notes.
   • For information on submitting a note, see Signing Clinical Notes.

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Canceling a Draft Note

To cancel a note means to close NoteWriter without saving any changes you’ve made in the note template. If you cancel a draft, NoteWriter closes and you are returned to the Clinical Notes summary list; the note remains in draft status, but any changes you made to the note since the last time it was saved are discarded. If you cancel a note you have not yet saved, the note is deleted. To cancel out of a note:

1. Tap Cancel at the bottom of the note template.
2. Tap Confirm in the confirmation pop-up that displays to cancel out of the note. NoteWriter closes and the note is saved in the Clinical Notes summary list. Draft notes appear in the list with Draft in front of their name, and with a status of Draft.

NoteWriter closes and you are returned to the Clinical Notes summary list. If you did not previously save the note, it is deleted

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Deleting a Draft Note

Deleting a note removes a note that you have saved in draft form. Draft notes can be deleted from the Clinical Notes summary list or from within NoteWriter. To delete a draft note from the Clinical Notes module:

1. Select a patient from the Patient List and then select the Clinical Notes module. The Clinical Notes summary is displayed. If you have any draft notes saved for the patient, they display in the summary list.
2. Identify the draft note you want to delete and then swipe right-to-left on that row in the list.
3. When the context buttons appear, select the Delete. The draft is removed from the list immediately.

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To delete a draft note from within NoteWriter

1. Select a patient from the Patient List and then select the Clinical Notes module. The Clinical Notes summary is displayed. If you have any draft notes saved for the patient, they display in the summary list.
2. Tap Add in the top-right corner. The NoteWriter screen opens and the Draft Notes section is expanded to show all of the draft notes for the patient.
3. Tap Delete at the bottom of the draft that you want to delete.

4. Tap Confirm in the confirmation pop-up that displays to delete the draft note. While in NoteWriter, you can continue another draft note (Continuing or Editing a Draft Note) or start a new note (Starting a New Note for a Patient).

5. To exit NoteWriter, tap Done.
6. If you are exiting NoteWriter without making any other changes, you may be prompted that unsaved changes will be lost. Tap Dismiss to exit NoteWriter. NoteWriter closes and you are returned to the Clinical Notes summary list.

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Viewing a Print Preview of a Note

You can preview a note at any time during the note creation process, from the time you start entering patient data into the note until you sign it. By previewing a note, you can review your notes for completeness and accuracy before you sign them. The print output of notes is standardized in NoteWriter, so that each note type is structured in a uniform way, regardless of the workflow used to create it. To preview a note:

• At the bottom of the note template, tap More and then select Print Preview from the menu. A preview of the entire note displays. Tap Close to close the preview window.

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Sharing Draft Notes

In Clinical Notes summary list is where everyone can see Shared Drafts. Draft notes may be shared to enable care team members (where allowed), to show drafts to other team members caring for a patient, without requiring a signed or final note. After a note has been shared, it can no longer be un-shared or deleted from the Commure Pro application. Providers who require co-signature can share a draft before submitting the note for signature. Providers who do not require a co-signer can share a draft with all who are able to view note for the patient. To share a draft note:

1. Open a draft note for editing. For details, see Continuing or Editing a Draft Note.
2. Tap Share at the bottom of the screen.
3. In the confirmation pop-up that displays, tap Yes to ave the note as a shared draft. NoteWriter closes and the note is saved in the Clinical Notes summary list. Shared draft notes appear in the list with a status of Shared Draft.

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Signing Clinical Notes

The process of signing a note is final; once you tap Submit, you cannot make additional edits to your note, so save your notes in draft form until you are certain that they are complete and accurate. After you tap the Submit button, you may be required to enter your Commure Pro password or a numeric PIN (Personal Identification Number). Or, if Apple’s Touch ID® or Face ID® feature has been set up on your device (see Establishing a Touch ID or Face ID for Logging In or Signing Orders), and has also been enabled by your administrator, you can use your fingerprint or facial image to sign your orders instead of a manually entering a password o PIN. Once you sign a note, your electronic signature is added to the last page of the finalized note. Electronic signatures include your first and last name, as well as the date and local time that you signed the note. For example: Electronically Signed by Dr. David Livingstone on 12/18/2020 at 8:28AM Depending on how your administrator has configured the system, any one of the following scenarios may apply:

• You are never required to enter a password or PIN (or to use Touch ID/Face ID) after you tap the Submit button.
• You are required to enter a password or PIN the first and every time that you tap the Submit button. If Apple’s Touch ID or Face ID feature is enabled on your device, after you enter your password or PIN the first time, you are then prompted to use the Touch ID/Face ID feature (instead of password or PIN) each time you tap the Submit button.
• You are required to enter a password or PIN the first time you tap the Submit button, and then the application “remembers” your this information for subsequent submissions in the same session. You are not required to enter it again unless you have a period of inactivity (no new note submissions) that is longer than a specific period of time defined by your administrator. Again, if Apple’s Touch ID or Face ID feature is enabled on your device, after you enter your password or PIN the first time, you are then prompted to use the Touch ID/Face ID feature (instead of password or PIN) whenever you have a period of inactivity that is longer than the defined time. To sign and submit a note:

1. Tap Submit at the bottom of the NoteWriter screen. You may be prompted to enter credentials to validate your identity. In addition, you may be prompted to confirm that you want to sign your note.
2. If an additional password, PIN, or co-signing provider are required, the Sign/Submit screen is displayed, containing one or more of the dialogs below is displayed. Complete each screen as follows, depending on what it requires:
   • Manual Entry of Password or PIN: Manually enter your password or PIN, and then tap Confirm.
   • Manual Entry of Password or PIN, plus Co-Signing Provider: Manually enter your password or PIN, and then enter the name of the co-signing provider (using the Search field or the Recently Selected list), and then tap Confirm. If only one provider can co-sign for you, that name is defaulted into the field for you.
   • Touch ID or Face ID in place of Password or PIN: If Touch ID or Face ID is enabled (and your Touch ID/Face ID has been established via Establishing a Touch ID or Face ID for Logging In or Signing Orders), then immediately after you tap Submit one of the following dialogs is displayed:
   • For Touch ID: “Touch ID for Commure Pro. Sign using your fingerprint.” Press your finger lightly on the Home button to register your fingerprint and immediately sign your note. If your fingerprint is not accepted for any reason, a Sign using pin/password option is automatically displayed. If you select this option, the Password or PIN field is shown. Enter your password or PIN and then tap Submit. - For Face ID: The Face ID logo is shown. Show your face to the front camera to register your identity and immediately submit your note. If your facial image is not accepted for any reason, a Try Face ID Again option is automatically displayed. Select the option and try again. Or tap Cancel, tap into the Password or PIN field, enter your password or PIN, and then tap Submit.

• Co-Signing Provider: If a password or PIN are not required, or if you used Touch ID/Face ID in place of manually entering the password or PIN, you may next see a dialog asking for the name of the co-signing provider. Enter their name using the Search field or the Recently Selected list, and then select Confirm. If only one provider can co-sign for you, that name is defaulted into the field for you. The note is finalized, and your electronic signature is added to the last page of the finalized note. The note is added to the Clinical Notes list as a final note, and you can no longer make changes to it.

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Adding an Addendum to Signed Notes

You may find that you need to clarify or supplement information in a note that you have already signed and submitted from within Commure Pro. In this case, you can create an addendum to document and append this additional information to the original note. The option to add an addendum is available if your user profile is configured for them or if you are part of a department that is configured for them. To add an addendum to a note:

1. Select a patient from the Patient List and then select the Clinical Notes module. The Clinical Notes summary is displayed.
2. Identify the finalized note in the list that you want to append and then start the addendum using one of the following methods
   • Swipe left in the row and tap Add Addendum (or you can swipe all the way across the row).
   • To review a note’s contents first, select the note in the list to open the note details screen, and then tap Add Addendum in the note header. The note opens in NoteWriter and the Addendum section displays the entire contents of the completed note in preview mode for reference.
3. Type your addendum into the Addendum Comments text field.
4. (Optional) If charges are enabled, you can tap Charges to enter charges while adding an addendum.
5. After you’ve entered the addendum into your note template, you may be ready to sign and submit your note, or you may want to save it as a draft so you can more additional edits later. Choose one of the following options for completing your work on the note.
   • Tap Save to save the note as a draft. For more information about working with drafts, see Saving a Note as Draft.
   • Tap Submit to sign and submit the note. For more information, see Signing Clinical Notes.
   • Tap Share to share a draft with another provider. For more information, see Sharing Draft Notes.