Documentation/User_Guide/08.html

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   6 <title>OpenEMR v3.2.0 Users Guide - Patient Notes & Transactions</title>
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  13 <h1>OpenEMR Users Guide (version 3.2.0)</h1>
  14 <h3>Table of Contents</h3>
  15 <ul>
  16 <li><a href="01.html">Getting Started</a></li>
  17 <ul><!-- InstanceBeginEditable name="TOC1" --><!-- InstanceEndEditable --></ul>
  18 <li><a href="02.html">Main Screen & Navigation</a></li>
  19 <ul><!-- InstanceBeginEditable name="TOC2" --><!-- InstanceEndEditable --></ul>
  20 <li><a href="03.html">Setting Up Your Clinic</a></li>
  21 <ul><!-- InstanceBeginEditable name="TOC3" --><!-- InstanceEndEditable --></ul>
  22 <li><a href="04.html">Adding a New Patient</a></li>
  23 <ul><!-- InstanceBeginEditable name="TOC4" --><!-- InstanceEndEditable --></ul>
  24 <li><a href="05.html">Using the Calendar</a></li>
  25 <ul><!-- InstanceBeginEditable name="TOC5" --><!-- InstanceEndEditable --></ul>
  26 <li><a href="06.html">New Encounters & Coding</a></li>
  27 <ul><!-- InstanceBeginEditable name="TOC6" --><!-- InstanceEndEditable --></ul>
  28 <li><a href="07.html">Issues & Immunizations</a></li>
  29 <ul><!-- InstanceBeginEditable name="TOC7" --><!-- InstanceEndEditable --></ul>
  30 <li><a href="08.html">Patient Notes & Transactions</a></li>
  31 <ul><!-- InstanceBeginEditable name="TOC8" -->
  32 <li>Patient Notes</li>
  33 <li>Transactions</li>
  34 <ul>
  35 <li>Referrals</li>
  36 <li>Basic Transactions</li>
  37 </ul>
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  39 <li><a href="09.html">Basic Billing</a></li>
  40 <ul><!-- InstanceBeginEditable name="TOC9" --><!-- InstanceEndEditable --></ul>
  41 <li><a href="10.html">Accounting & Receivables</a></li>
  42 <ul><!-- InstanceBeginEditable name="TOC10" --><!-- InstanceEndEditable --></ul>
  43 <li><a href="11.html">Reporting</a></li>
  44 <ul><!-- InstanceBeginEditable name="TOC11" --><!-- InstanceEndEditable --></ul>
  45 <li><a href="index.html">Index</a></li>
  46 </ul>
  47 <br />
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  54 <h2>Patient Notes & Transactions</h2>
  55 <p>Patient notes store  patient information that is unrelated to the patient's medical  condition. Such information may include outstanding balances,  changing insurance information or patient requests for actions by the  clinic.</p>
  56 <p>Transactions are somewhat  similar, but  record events that have already occurred. These may be  referrals, requests from either the patient or the doctor, or legal  transactions.</p>
  57 <h3>Patient Notes</h3>
  58 <p>To begin, log in to  OpenEMR, and use the search function in the lower left-hand corner to  locate the patient for which you would like to add a note. </p>
  59 <img src="processed/088.png" />
  60 <p>Click on the desired  patient to bring up the 'Summary' page.</p>
  61 <img src="processed/089.png" />
  62 <p>If the user is not  Authorized they will be unable to see the patient's medical  details such as issues, immunizations and prescriptions.</p>
  63 <p>Click 'Notes (more)' to add a note for  this patient.</p>
  64 <img src="processed/090.png" />
  65 <p>The 'Patient Notes' page  will present you with a text box for entering the note, as well as  drop-down lists for selecting the type of note, and the person to  whom the note is addressed.</p>
  66 <p>Type your note in the text  box and click 'Add New Note'.</p>
  67 <img src="processed/091.png" />
  68 <p>The new note now appears  in the list of notes on the same screen. The checkbox is used to  control whether the note is &quot;active&quot;. Above are options to  view only the active or inactive notes. </p>
  69 <p>Click 'Patient Notes  (back)' to return to the patient summary.</p>
  70 <img src="processed/092.png" />
  71 <p>The new note is now listed  on the Summary page.</p>
  72 <h3>Transactions</h3>
  73 <p>Select 'Patient/Client –  Visits - Transact' from the navigation menu to go to the Transactions  page.</p>
  74 <p>The Transactions page  contains two basic form types.  A simple form for internal  transactions such as patient requests or billing transactions, and a  Referral form.</p>
  75 <h3>Referrals</h3>
  76 <p>Click 'Add Transaction'  and select 'Referral' from the drop-down list to begin a new Referral  transaction.</p>
  77 <img src="processed/093.png" />
  78 <p>Another drop-down contains  a list of physicians and clinics from the Address Book to which you  can refer your patient.  Select the referring physician, risk level,  etc., and enter a reason for the referral.</p>
  79 <img src="processed/094.png" />
  80 <p>Click 'Save Transaction'.</p>
  81 <p>The referral is now in the  Patient Transactions list. </p>
  82 <img src="processed/095.png" />
  83 <p>Click 'Referral' next to  the transaction to generate a printable version of the Referral form.</p>
  84 <p>Depending on your system's  configuration, you may be asked to save the file, or it may be  printed automatically.</p>
  85 <img src="processed/096.png" />
  86 <p>When you are finished  return to the Transaction list and click 'Add Transaction'.</p>
  87 <h3>Basic Transactions</h3>
  88 <p>Other transaction types  use the simple transaction form. Select the desired type from the  list and enter the  transaction details in the text box provided.   Click 'Save Transaction' when finished.</p>
  89 <img src="processed/097.png" />
  90 <p>The new transaction has  now been added to the list along with the referral.  Click on the  date of a transaction to edit its contents.</p>
  91 <img src="processed/098.png" /><br /><br />
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