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Tebra Help Center

Sign Clinical Note

Updated: 06/09/2023|Views: 5230

A note is the clinical documentation for a specific patient visit and can include problems, medications, allergies, immunizations, history, assessment, and treatment plan. Clinical notes can be edited until they are signed. Once the clinical documentation is completed, the provider signs the note to finalize the visit. If additional edit are required after the note is signed, add an addendum.

Open notes can be accessed from various locations: the patient's appointment on the Dashboard, Open Notes, or the patient's Notes tab.

Access Clinical Note

  1. Hover over the Platform icon and click on Dashboard. The Dashboard opens.
  2. Click the In Office or Finished tab. The patient appointments displays.
  3. Click on the patient's appointment to view the appointment card.
  4. Click Create Clinical Note. The saved note opens.
Clinical_Note_AccessEdit.png

Sign Clinical Note

  1. Review the clinical note and document or modify the note, as applicable.
  2. Click Sign to finalize the note. The note is saved and the status is Signed.
    Note: Only providers have the ability to sign a clinical note.
    • To request a co-sign, click the up arrow and select Sign and request Co-sign. The Request Co-Sign pop-up window opens. Select the co-signing provider and click Sign & Notify.
Clinical_Note_SignNote.png
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