Daily Note

Completing the Daily Note copied from another document

When a Daily Note is being copied from an Evaluation, Progress note, or Discharge, Heno will map in the following fields from the main documentation to the Daily note:

• Subjective
• Objective
• Assessment
• Additional Plan text
• Medications
• Short term goals 1-5
• Long term goals 1-5
• Flex fields 1-5
• Charges from the Initial Evaluation

Please check out this article to see how to create the Daily Note from other documentation:

Once you are in the daily note, you will have the option to Update information that copied over, write in additional boxes that are available, and use the Experience log/Flowsheet from the Actions Menu. You will be able to use the quick texts that have been created for the daily note as well:

If you added CPT charges in the other documentation or in the Experience log/Flowsheet, you will be able to see and access this information to update, edit, or change inside of your daily note. 

Once you are ready to approve your documentation, click on the Action Menu -> Approve to finalize the documentation:

After Approving the document, this will take you directly into the Check out screen. You will be able to add and edit CPT codes if needed.

Please check out this article on how to edit CPT codes in the check out screen: Adding CPT and Checking out

Then scroll to the bottom and either select Ready for Check Out or Check out

• Red: Ready for Check Out - This will change the status on the schedule to (RFC) and give the front office the opportunity to collect Co-insurance, general store orders, and statements balances.
• Green: Check Out - This will skip the front office and send the billing directly to the Encounter (Pre-Claims area) for the billing team

There are several ways to access the documentation. For this portion of the article, we will be using the hover over on the schedule. The ability to that the documentation will be available one the appointment has been checked in (CI). 
If you are interesting in other ways please check out this article: 

Once the appointment is checked in, hover your mouse over the appointment to view the documentation that is available. Click on Daily Note:

This will bring you to the creation page of the Daily Note. Click the blue Create Button:

Inside of the document, there will be a Left and a Right side with tabs.

Left Side (Red):

• Note History: This is where you will be able to view previous Daily Notes linked to this patient's Chart
• Patient: You will be able to view patient's chart details here
• Documents: This shows the information in the patient's profile including completed Heno documents, incoming and outgoing faxes linked to the patient, and any uploaded files tot he patient's account
• Experiences: This is a quick view to the experience log. If you are using the flowsheet, you can review the information in this area as well without leaving the page.

Right Side (Blue):

• Show all: This will show both of the tabs at the same time
• Charge: Any CPTs added to this appointment will show here. Including if CPTs were added in an Eval/PN/DC or if CPT codes were added to the Flowsheet/Experience log.
• Note: This will show the current note that is open for today
• Template: Classic Templates added during the Initial Evaluation, Progress Note or Discharge can be updated here, if a IE/PN/DC is completed the same date as the DN the ROM measurements, the values must be altered in the IE/PN/DC.

To start documenting, you will have the option to 

1. Type on the right side with the Note area any information relating to the appointment

2. Use the Copy/Copy from IE/PN from the Note History tab on the left side:       

   • Dark Pink Box:
     • Quick Copy: Only copies the notes. Codes and Experiences will not be copied
     • Copy: Will allow you to copy the Note, Experiences, and CPT codes. This will also allow you to change the rendering provider if different for this appointment all in one step.
   • Orange Box:
     • Copy from IE/PN: Will copy from the initial evaluation or progress note from current visit or from a previous visit if you are copying for a follow-up appointment.

You will then have the option to use the Experience Log or the Flowsheet to update the exercises and activities for today's treatment along with adding CPT codes attached to the experiences.

1. Access the Flowsheet using the Action Menu
   

2. Access the Experience Log (classic) Using the Action Menu

There is also the experience log into the documentation in the Experience tab:

You will be able to scroll down the left side to update today's document in the Note section. You will have access to any quick text that were created:

When HENO's classic templates are used with a patient during the Initial Eval, Daily Note or Progress Note - an additional section is now available to notate. 

The Daily note will display Classic Template values from first IE in chart, the 3 most recent visits, and then allow updates to them with the current measurements.

*****Within our upcoming October 2021 Release, The temple will now have the ability to add a + symbol to the fields to dignify positive and negative numbers.*******

Approve and Send - Fax and Email

Checking out the Appointment