Use Notes in Insight
This user guide describes the proper use of the five different types of Notes in Insight EMR: notes for Patient, Case, Appointment, Precaution, and Account (as listed in the columns of the table below).
Notes provide additional information about your patient, your patient’s case, appointments, precautions, and account. Each note has a specific intended use, and using the notes functionality correctly helps your entire team manage your caseload effectively.
|Patient Notes||Case Notes||Appointment Notes||Precaution Notes||Account Notes|
|Where Entered||Additional Information section of the Personal Information tab in the Client Editor||Case Notes area in the Case Information tab in the Client Editor||Notes area in details for a selected appointment||Precautions tab in the Client Editor||Notes area in the Personal Information tab in the Client Editor|
|Visibility||Appointment detail for all appointments for the patient||Can be included in letters sent to patients or physicians||Appointment detail for selected appointment and some reports||Pop-up reminder for the therapist in charting, might be included in the header||Insight Billing account information|
|Example Uses||Remind staff about useful information regarding the patient that would be useful to see for all appointments||Patient and physician discussions about the patient's case||Set reminders for patients, notes on reasons for patient no shows||Remind therapist about important medical precautions||Information about the patient's account and claims|
Patient Notes (additional information)
Patient Notes are entered in the Personal Information tab of the Client Editor, in the area labeled Additional Information, as in this example.
Patient Notes are used for any incidental information about the patient that would be helpful to see on the schedule and appear in the appointment details.
Because the information contained in these notes appears outside of the patient’s record, Patient Notes should not include any Protected Health Information (PHI).
Case Notes are clinical notes about the patient’s case. They are entered on the Case Information tab in the Client Editor. These Case Notes are generally added by the therapist, and are often used to document conversations with the patient or the referring physician that occur outside of a patient visit.
It is best practice to date all Case Notes as illustrated in the example.
Case Notes may be viewed in the Notes area on the Case Information tab:
Case Notes may also be included in letters that are intended for physicians or patients. In the following example, the Case Notes written on 5/21/16 are inserted in a Discharge summary that is sent to the patient’s physician.
Case Notes should never include financial information. They are to be used exclusively for information about the patient’s Case.
Appointment Notes are entered in the Appointment Note area, and may be added while creating an appointment, or when editing the appointment later on:
Appointment Notes appear in the appointment detail area when the user clicks on an appointment:
Precaution Notes are entered on the Precautions Tab in the Client Editor.
Precautions appear as a pop up warning, highlighted in red, to the therapist when clicking on the patient’s name in charting:
Precaution Notes are often included in the header of clinical reports:
Account Notes may be entered from the Personal Information tab of the Client Editor:
Account Notes are visible, along with appointment notes in the Notes area of the Personal Information tab. Account Notes are also visible in notes about the patient’s account used in Insight Billing: