Procedure NoteWriter is when a provider documents a procedure with the NoteWriter activity which generates note text based on the point-and-click documentation. Charges can then be generated automatically for a procedure based on the documentation in the NoteWriter.

Resources

The following resources provide information on Procedure NoteWriter functionality.

• Brief Op Note - (Handout) To support patient safety and meet regulatory requirements, a brief op note describing key elements of all procedures needs to be completed immediately following a surgery.

• Central Line Insertion - (Handout) For central line and PICC line insertion, or dialysis catheters, the workflow begins with a provider placing the appropriate Order Set. The nurse then acknowledges the orders and documents the TimeOut and Checklist prior to the start of the procedure. Finally, the Checklist documentation is reviewed and a Bedside Procedure Note is created by the provider using NoteWriter.

• Changing Providers from Procedure NoteWriter - (Handout) The Authorizing Provider and Performing Provider must be documented correctly when a procedure is performed in order for the correct charges to be filed.

• Documenting a Procedure Note using NoteWriter - (Handout) Using NoteWriter to document procedures combines the following actions into one workflow: linking (or creating and linking) a procedure order to a procedure note and dropping a charge. This activity is available for both outpatient and inpatient (bedside) procedures.

• Using .procdoc in a Clinic Note - (Handout) The .procdoc SmartText can be used within a Clinic Note to include procedural documentation. This functionality will only work if the note is opened in the Notes Sidebar and the workspace is not overly minimized.

Related Pages

• NoteWriter

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