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Signing clinical notes

A provider can digitally sign a clinical note to indicate his or her approval of the note. Signing a clinical locks it to prevent changes from being made to the text and to prevent the note from being deleted; however, a signed or locked note can be appended to.

Notes:

·        Depending upon a certain global setting, you may not be able to sign clinical notes.

·        Depending upon certain global settings, clinical notes can also become locked automatically after a specified length of time, when saved, or during the month-end process; or they may never lock.

·        A certain global setting (for educational institutions only) makes it so that a student and then an instructor must sign clinical notes to lock them.

Tip: You can sign multiple clinical notes at the same time from the Office Manager.

To sign a clinical note

1.   With a patient selected in the Patient Chart, on the File menu, click Clinical Notes.

The Clinical Notes window appears.

2.   Select the page of the clinical note you want to sign.

Note: If passwords are enabled, the user must have rights to "Clinical Notes - Add Signature" to add a signature.

3.   Click the Sign Clinical Note button on the toolbar.

The Approval Verification dialog box appears.

4.   Type your User ID and Password, and then click OK.

The Sign Clinical Note dialog box appears.

The Name, which corresponds to the User ID entered from the Approval Verification dialog box, and Date, which is the current system date, cannot be changed.

5.   In the signature box, sign your name.

6.   If you need to clear the signature to re-sign, click Clear. This button is unavailable if a signature was entered and saved previously.

7.   Click OK.

Notes:

·        When a signature has been added to the clinical note, a "Signed on [date]" stamp is added to the end of the clinical note.

·        If you select a clinical note that has been signed, the Sign Clinical Note button changes to the Signature button . To view a signature for the selected clinical note, click the Signature button.