Navigate a Note
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An encounter note is the clinical documentation for a specific patient visit and can include problems, medications, allergies, immunizations, history, assessment and treatment plan. Within Kareo EHR, you can create various encounter notes to document all aspects of a patient's visit.
Navigate to Patient Chart / Notes
- Enter the first 2–3 letters of the patient's name in the top navigation bar search box.
- Click to select the patient from the auto-populated results. The patient's chart / Face Sheet opens.
- Click Notes in the left menu. The Notes page opens.
- Click + Create Note at the top right. A new Note opens.
- Note Type: Click to select the type of encounter note (i.e. SOAP, H&P, Nurse Visit, etc.). You can change the note type at any time.
- Assigned To: If desired, assign the note to another user. Assigned notes display in the Tasks feature under the Open Notes tab. Notes can only be assigned to users with the role of provider or clinical assistant.
- Clear Note: Clears all information from a note so you can start over.
- Select date and time of the visit. If a note is created from a patient appointment, the date will default to the appointment date. If a note is created from the patient chart, the date will default to the current day.
- Click on any section links to add/modify information within the note.
- Patient Information: Click Face Sheet to view summary data while working in the note. Click Immunizations to view or add immunizations.
- Patient Notes: The last five notes are displayed for easy access to the history of a patient's visits and treatment plan. Click on the date to view and copy the note if desired.
- Note Sections: Click on any section to view/add information within the note. To remove a section from the list, click . To add one or more sections, hover over +Optional and click .
- Labs/Studies: A list of past labs. Click on a link to view details.
- Documents: A list of documents attached to patient's chart. Click to view from within a note.
- Sign: Click to finalize a note. Once signed, no further changes can be made to the note; any changes you need to make will be added as an addendum to the note.
- Superbill: Click to capture a comprehensive list of charges for the exam, procedures, supplies and other goods and services provided during the patient visit.
- Copy: Click to use an existing note as a basis for a new note.
- Referral: For Meaningful Use. When there is a change of physician for the patient, select either "Receiving" for new patients from another practice, or check "Transferring" for patients moving to specialty care or leaving the practice. To send a referral, click Send Referral by and select to send either by direct message or eFax. See also View Referral History.
- Care Checklist: Access and note any items on the Care Checklist, as required by Meaningful Use.
- Save & Close: Click to close and save the note. The note is marked as "Incomplete" until it is signed. After saving a note, if the note is in error, you can mark it so (see Mark a Note as Error).