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OpenEMR : Patient Notes & Transactions. Based on OpenEMR 4.1 Laboratory Informatics Institute January 2014. OpenEMR : Patient Notes & Transactions. Patient Notes Transactions: Referrals Transactions: Basic. OpenEMR : Patient Notes & Transactions.

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openemr patient notes transactions

OpenEMR: Patient Notes & Transactions

Based on OpenEMR 4.1

Laboratory Informatics Institute

January 2014

openemr patient notes transactions1
OpenEMR: Patient Notes & Transactions
  • Patient Notes
  • Transactions: Referrals
  • Transactions: Basic
openemr patient notes transactions2
OpenEMR: Patient Notes & Transactions
  • Patient notes contain information not related to the patient medical condition. Things like outstanding balances, changes in insurance, patient requests from the clinic.
  • Transactions record events that have already occurred. Legal transactions, requests from the doctor, or the patient.
openemr patient notes transactions3
OpenEMR: Patient Notes & Transactions
  • To add a patient note: login to OpenEMR and find the patient you wish to add the note to.
  • Remember you can search for patients, using the function in the lower left corner.
  • Click on the desired patient’s name to be taken to their summary page.
  • Unauthorized users will not be able to see information on immunizations, prescriptions, or medical conditions for the patient.
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OpenEMR: Patient Notes & Transactions
  • Click edit next to the notes section, and then select add.
  • This will present a drop down menu for the type of note and the addressee of the note.
  • Type the note in the text box and then save it, by clicking save as new.
  • The check box is used to mark a note as active. Click on sent items to view previous notes, or view patient to return to the summary.
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OpenEMR: Patient Notes & Transactions
  • Clicking transactions at the top of the summary page will take you to the patient transaction page.
  • Transactions contains a page for internal transactions: billing and requests.
  • Transactions contains a page for referrals.
  • Click add and select referral to begin the referral process.
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OpenEMR: Patient Notes & Transactions
  • Use the drop down menu to select the physician you wish to refer the patient to and additional information, such as risk level.
  • Click save to save the referral to the patient transaction page.
  • Click print to generate a copy of the referral form. Your system may also ask you to save the file.
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OpenEMR: Patient Notes & Transactions
  • When you are finished, return to the transaction list and click add.
  • Non-Referral transactions use the simple transaction form.
  • Select the type of transaction from the drop down menu.
  • Enter the details in the text box.
  • Select save.
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OpenEMR: Patient Notes & Transactions
  • Click edit next to the transaction to edit the contents as needed.
  • Note that both the referral and the basic transaction are now showing on the transaction list for the patient.