The workflow for a chart/op note to get committed to the record will vary depending on your user account setup, your staff member's accreditation level, the treatment being delivered during the patient encounter, and your state regulations. Depending on these factors, non-MD users may be able to commit some treatment notes but not other treatment notes. All user capabilities are determined based on their user account setup.
In this article you'll learn about:
- Difference between Provider and Staff
- Providers, committing their own notes
- Staff, requiring an MD to Commit Their Note
- Provider, requiring an MD to Commit Their Note
In User Accounts, users are set up as either Staff or Provider by Title:
- Providers: can commit some or all of their chart/op notes
- Staff: require an MD to commit all of their chart/op notes
Note: in this article the term MD can be another provider without Doctor of Medicine credentials but is the user who needs to commit the note.
In this article you will learn optimal workflows for the following scenarios:
- Provider commits their own chart/op note
- Staff requires an MD to commit their chart/op note
- Provider requires an MD to commit their chart/op note
Provider Commits Their Own Note
As a provider, if state regulations allow your level of accreditation to commit the chart/op note based on the treatment being delivered, then follow this workflow:
- Use the Save button while you're still editing the note
- Once the note is finalized, use the Commit button to commit the note to the record
Note: In order to avoid data inputs being lost unintentionally, a warning will appear when a chart or procedure note is closed, instead of using the Save or Commit options, if there is any content in the note such as sketches or documentation.
Staff Requires an MD to Commit Their Note
As staff, if your notes always need to be routed to an MD for commitment, then follow this workflow:
- Use the Save button while you're still editing the note
- Once the note is finalized, use the Finish button to forward the note to the MD identified in the Approval By field of the note.
Note: the MD will not have any visibility of the note while the note is in Save mode. This prevents the MD from committing the note before it is ready. Once staff selects Finish, staff can no longer edit the note but can add an addendum.
- The selected MD will receive a dashboard notification to review and commit the note.
Provider Requires an MD to Commit Their Note
As a provider, if state regulations require your level of accreditation to have an MD commit your note based on the treatment being delivered, then follow this workflow:
- Approval By is set to the provider who starts the note by default. If the note is started by a staff member, the Approval By field will be filled with the admin of the practice by default.
- Provider should use the Save button if the note requires editing. This creates a dashboard notification to remind the provider to complete the note.
- Once the provider is ready for the MD to review the note, the provider changes the Approval By to the MD and clicks the Save button.
Note: the MD will not have any visibility of the note while the note is in Save mode and Approval By is still assigned to the original provider. This prevents the MD from committing the note before it is ready. Once provider changes the Approval By to the MD and selects Save, the provider can no longer edit the note but can add an addendum.
- The MD will receive a dashboard notification to review the note and clicks the Commit button to commit the note to the record.