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  • CPRS - Selecting the Correct Note Title
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The Importance of a Correct Note Title

Picking the correct note title helps with billing and data tracking, plus it makes it easier to find the right information when you need it later.


To start your note, click on the New Note button (bottom left corner of the CPRS screen):


Patient Location/Service

Instructions

Screenshot
(click on the image for a larger view)

Neurology Clinic (New Patient)

  • The first visit with a new patient in the neurology clinic is a consult.
  • Some patients are referred back for a consultation on a new problem, these patients also should have a consult pending and will need a new patient note.
  • If there is no Neurology consult pending to select, write your note as if it was a return visit / follow-up note.# For the Progress Note Title, choose "NEUROLOGY CONSULT"# For the Author, select your name (i.e. the resident).# For the Expected Cosigner, choose the attending who staffed the patient.# Select the Neurology consult request from the list of pending consults.# Click "OK".

Neurology Clinic (Return Visit / Follow-up)

  1. For the Progress Note Title, choose "NEUROLOGY OUTPATIENT FOLLOW-UP"
  2. For the Author, select your name (i.e. the resident).
  3. For the Expected Cosigner, choose the attending who staffed the patient.
  4. Click "OK".

ER / Urgent Care
OR
Inpatient on another service (either an initial consult or reconsultation via a new CPRS consult)
OR
Outpatient in another clinic

  • All ER / Urgent Care encounters are consults.
  • Whenever the ER / Urgent Care, another inpatient service, or another clinic asks the neurology service to see a patient, they MUST put a Neurology consult request into CPRS.
  • If there is no Neurology consult pending to select, ask the requesting resident or attending to place a consult in CPRS. If they do not know how to do this, you can enter a consult request yourself for them, but this is not ideal.
  • Just as with selecting the encounter, you should never choose an encounter other than the Neurology encounter. The ER/Urgent Care and other encounters are for those services, not Neurology.# For the Progress Note Title, choose "NEUROLOGY CONSULT".# For the Author, select your name (i.e. the resident).# For the Expected Cosigner, choose the attending who staffed the patient.# Select the Neurology consult request from the list of pending consults.# Click "OK".

Inpatient on the Neurology Service (NOT the admission note)
OR
Inpatient on another service (consult follow-up)

  • This is not used for the admission note for the patient. The admission note will be either a consult note or an admission H&P if the patient is a scheduled admission.# For the Progress Note Title, choose "NEUROLOGY INPATIENT".# For the Author, select your name (i.e. the resident).# For the Expected Cosigner, choose the attending who staffed the patient.

Scheduled Neurology service admission
OR
Admission Note for a Patient Seen in Clinic

  1. For the Progress Note Title, choose "HISTORY AND PHYSICAL NOTE/INPATIENT".
  2. For the Author, select your name (i.e. the resident).
  3. For the Expected Cosigner, choose the attending who staffed the patient.

Telephone calls

  1. For the Progress Note Title, choose "NEUROLOGY TELEPHONE".
  2. For the Author, select your name (i.e. the resident).
  3. For the Expected Cosigner, choose the attending who staffed the patient.

Procedures

  1. For the Progress Note Title, choose "NEUROLOGY PROCEDURE".
  2. For the Author, select your name (i.e. the resident).
  3. For the Expected Cosigner, choose the attending who staffed the patient.




Note Title Selected?

Once the correct note title has been selected, it's time to write a note.



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