Documentation - ED Medical Officer

• Highlight the patient from the tracking board 
• Select the Documentation icon from the toolbar

• Click on the + Add in Documentation

• Select an ED documentation type: 
  • ED Medical Progress Note
  • ED Medical Assessment
  • ED Discharge Summary
  • ED Letter

• Select Note Template: 
  • For ED Medical Progress Note select Progress Note (Free Text), Progress/SOAP Note, or
    Progress Note with Medications
  • For ED Medical Assessment select Progress/SOAP Note or Progress Note with Medications
  • For ED Discharge Summary select Discharge Summary (Medical)
  • For ED Letter select Letter template (Free Text)
• Click OK

Adding and Removing Content

Hover in each sub-section and click the button to: 

1. Refresh 
2. Insert free text 
3. Remove the section from the note

• To insert ED Medical Autotext: type .edm to open the Autotext options
• Double click on the required phrase or using the keyboard, find the required phrase and hit Enter

• Tagged results are automatically added to the discharge summary template in Results Review

• Tagged text is available to the left of the template and can be dragged into the relevant section
•  A superscript and reference text will be added to say that this was tagged from another note/author

Note: To learn how to tag pathology results and tag texts, please follow the QuickStart below: 

• Tag Pathology Results via Mpage and Tag Text

Saving and Signing 

There are several options when completing documentation:

• Sign/Submit - The document is complete and additions will be in the form of an Addendum at the bottom of the document
• Save - The document is in progress; it is saved but remains open; in this state it can be modified and signed by the original author or other staff
• Save & Close - The document is in progress, it is saved and closes; in this state it can be modified and signed by the current author or other staff
• Cancel - Opens the Unsaved Changes pop up; select Discard Changes to revert the note to its previously saved state

Viewing Dynamic Documentation 

There are several areas in PowerChart to view Dynamic Documentation, select from the following tabs in patient chart menu:

• Documentation
• Clinical Notes
• ContinuousDoc