NoteForm Section

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Version Information

Description

This is the section dictionary for v11 Note. It is used to define/create specific note sections. This dictionary replaces the prior "misc." sections found in v10 note functionality.

Note: There are several new delivered note form sections. They are identified below:

  • End of Encounter Meds - This section details the patients medication list at the end of the visit encounter. It reflects changes made to the current med list and also includes newly ordered medications.
  • Future Appointments - This section contains the patients list of scheduled appointments.
  • Patient Care Team - This section allows the user to manually add treating providers to the patient's care team from within the note.

Definition

NoteForm Section1.jpg

  • Code - The Code is a unique identifier that must be supplied. This is not displayed in the product and is used for identification purposes only.
  • Name - This is the name that will appear for the end users in the EHR application. This should be unique to prevent confusion.
  • Mnemonic - This is not required, but it used as a secondary identifier. This does not appear in the product and unless you have another use for it, the recommendation would be to make this the same as the code.
  • Inactive - The inactive flag allows you to inactivate or hide an entry. If an item is inactivated, users would not have the ability to select the allergen in the future, although any patients with the allergen defined would remain viewable.
  • Enforced - The enforced flag designates whether a dictionary item is required and cannot be changed. In most cases, this comes predefined by Allscripts and should not be selected for new entries. If an entry is enforced, it cannot be modified or inactivated.
  • Clinical Order - This is a numerical value that determines where the section will fall in the noteform section list. For example, if Active Problems was assigned a clinical order of "100" and Social History was assigned a clinical order of "200" and a new section is created that should fall between the Active Problems and Social History, it could be assigned a clinical order of "150" because it would fall between "100" and "200". Please note however that most noteform sections can still be reorganized within the Note Input and Output templates even though they have a pre-defined "clinical order".
  • Line Spacing Between Note Forms - A numerical value between 0 and 9, which indicates the number of spaces that should be applied between the end of one note form under a given note section and the beginning of another note form within the same note section. This only applies when there is more than one note form being used in a note section. It does not apply to the spacing within a note form.