By Dr. A. Carbonell
Administrative Notes can be used when completing chart reviews or reviewing labs or imaging, these do not give any credit for the provider as they do not generate a bill but are useful for documenting information in the chart.
1. Go note the Notes tab, Select New Note and type Administrative note
2. This will generate a blank note for documentation only but will not give credit to nursing or to the provider
Examples of when to use these notes:
1. If you review labs/imaging/consults/microbiology/etc. and need your nurse to call the patient with some information in regards to starting a medication or making a treatment plan change, you can document all the changes in an administrative note and alert your nurse by adding your nurse as an additional signer to the note to alert your nurse to call the patient
a. Once you complete your note, sign the note then right click and select identify Additional Signers and select your nurses name to send the alert to them (you can send alerts to multiple people therefore you can select RN only or RN and LPN if appropriate)
2. If you received recommendations from consultant, you can also make an administrative note and let your nurse know to call the patient with the recommendations
3. If a consultant asks for imaging, once the imaging is completed you can also alert the consultant that the imaging is done. (this is only appropriate for existing consultants not new consults)
Examples:
1. To RN: “Please alert the patient that his blood sugars are not at goal on his labs and that I have added alogliptin 25 mg daily to his diabetes regimen. Please let him know also to make a lab appointment in 3 months to recheck his diabetic labs”
2. To Consultant: “Alerting neurosurgery in that MRI L-spine has been completed further review”
3. To consultant: “Alerting endocrinology that updated diabetes labs have been completed”
4. To RN: “Please let the patient know that his urine culture came back with infection and that I have ordered Macrobid for the patient to take, please let him know to call the pharmacy to activate and pick up today”