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 • 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 & 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.
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.
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.
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.
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.
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.