Creating an Administrative Note

Creating an Administrative Note

Creating an Administrative Note

What is an Administrative Note? 

 

The Administrative Note allow you to clear out a Chart Face so that it is all set for future admissions (MAR Status should be enabled for the patient to generate this type of Note)

 

 

 

. Specifically, it allows you to:

 

  • Clear ("Stop") all medications and take them off the MAR
  • Resolve all diagnoses in Axis I and clear out Axes II-V
  • Clear all orders from the Clinical Order Sheet
  • Clear out any lab requisitions

 

This is useful when a patient is discharged, as it prepares the Chart for future admissions. If you opt to clear out any of the above information, the fields will be clean and ready for new information when the patient is readmitted to the hospital or any other setting. 

 

1.  When you discharge a patient, you may select to inactivate the Chart from the  button. Start off by changing the patient's status to 'Inactive' in the upper-left corner of the Chart Face. 

 

 

 

 

2.  A window will appear with the patient's name, ID, DOB, and age. Click 'Verify' to acknowledge that you want to change the patient's status. 

 

 

 

3.  Click 'Yes' in the dialog that appears asking if you would like to create an Administrative Note. 

 

 

 

4.  The next dialog presents the various things you can clear out to prepare the Chart for the next admission. Once you choose the desired options, click 'Continue' to create the Administrative Note.

 

 

 

5.  You will be directed to the Work Areas of the Administrative Note, which is essentially the Nursing Note layout. Text will auto-populate indicating the actions you took in the previous dialog. 

 

 

 

6.  Once you're finished with the Administrative Note, click  in the lower-right corner of the Work Areas.

 

 

7.  The compiled Administrative Note will look like this:

 

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