EMR - Progress Note

Progress Notes are normally performed every 30 days to show the progression of a patient's diagnosis for their primary physician and/or for Medicare requirements. There are also Re-Evaluations that can be used in the system. These two notes are very similar and are used for the same purposes. Some clinics prefer to use progress notes, some prefer re-evaluations, and others might even use both. For example, progress notes could be done every two weeks while re-evaluations are performed every thirty (30) days. How you choose to use these different medical records is completely up to you.

If the daily Visit Notes and the Care Plan have been completed for a case, the progress notes are really pretty simple to complete. All of the tabs and the way that data is entered on them have already been covered in the pages referencing the Evaluation, Visit Note, and Care Plan, but will be mentioned here again briefly.

The third tab will list the Progress Notes in area #1 if any are entered in the database already.

Click the "New Progress Note " button (#2) to start the progress note. The screen below will appear.

Once the progress note is saved, the date and the comments will be shown on this tab.

For more information on the features of this screen, see EMR Chart under Documentation.

When entering a Progress Note, the only required fields are marked with an asterisk (*). These include the date of the note and the provider name. All other fields are optional.

The Progress Note is made up of several Tabs and there is a lot of information that could be entered for this medical record. There are also several features that can make data entry quicker.

This screen contains drop-down lists that are common to the system. To learn how these operate, see Drop Down Lists under Common Program Features.
These tabs also contain many Search Boxes that are customizable. The screenshots below show what the field labels will be by default. These labels can be changed for each different patient type that is added to the system on the Patient Types screen. For more information on how the Search Boxes function, see the section under Common Program Features.

Tab 1 - General

The "Complete" check box is common to all notes. Marking a note as complete will add that particular note to a "Batch" of notes. If the option to "Lock Completed Notes" is checked (see Options), only users marked as Administrators will be able to make changes to a note once it is marked as Complete.

A lot of information on the Progress Note is actually "pulled" in or carried forward from other notes already in the system. Goals are brought in from the Care Plan(s) on file, current measurements are brought in from the last daily Visit Note that was entered, prior measurements are copied from the first daily Visit Note that was entered, and the Other Objective fields are copied in from the last Visit Note entered.

This first tab contains four large text boxes. If fields are "mapped" from other notes to these fields, the entire progress note could almost be completed as soon as it is created! (See Field Mapping for more information).

Note Date	Date of the visit or date the note is being created.
Provider	Provider completing the note.
Next PN Date	Date the next progress note will be due. This defaults to 30 days after the Note Date. If the Note Date is changed, update this field if necessary!
Next MD Date	Date of the next physician visit for the patient.
Fields 1,2,3,4	Large text fields.
Note Dates	These dates determine which measurements appear on the progress note. When first creating a progress note, the Note Dates are filled in automaticaly. The system will search for the last visit note on file and the first visit note on file and place these dates in the text boxes for you. To change the dates so that different data is displayed, click the box beside the note date and select a different note date from the list that appears by double-clicking on it. (See figure below).
Care Plan Dates	These dates determine which goals appear on the progress note. When first creating a progress note, the Care Plan Dates are filled in automaticaly. The system will search for the last care plan on file and the first care plan on file and place these dates in the text boxes for you. To change the dates so that different data is displayed, click the box beside the note date and select a different note date from the list that appears by double-clicking on it. (See figure below).
Print Prior Measurements	When printing the Progress Note, determines if the prior measurements are printed along with the current measurements.

Tab 2 - Goals

The goals from the Care Plans are automatically shown based on the Care Plan Dates on the first tab (see above). Goals can be updated on this screen and new goals can also be added to this screen. When adding goals on this screen, they will get added to the last Care Plan on file automatically. If no Care Plan is on file yet, one will be created. For more information on how goals are entered, please see Care Plans.

Tab 3 - Current Objective

Current measurements are also copied in automatically based on the "Current" note date on the first tab (see above. These measurements can be modified on this screen and the corresponding visit note will be updated at the same time.

Tab 4 - Prior Objective

Prior measurements are copied in automatically based on the "Prior" note date on the first tab (see above. Unlike the Current Objective tab, these measurement CANNOT be updated on this screen.

Tab 5 - Other Objective

This tab is a copy of the Other Objective tab found on the Visit Note screen. It gathers data from the "Current" note date found on the first tab (see above). Any changes made on this tab will be reflected in the corresponding Visit Note.

Tab 6 - Custom

The final tab is reserved for any additional fields that you may want to add to the Progress Note. To add additional fields, change the "NOT USED" fields on the Patient Types screen to whatever you would like them to be. Once you create a custom field, it becomes a Search Box so that you can also create a list of choices for it!