A case note is a non-billable note that is still clinically relevant. For example, when you answer questions from a patient over the phone. While the conversation isn’t billable, you can document the communication in a case note.
Create a Case Note
To create a case note, navigate to the Patient Record Actions and select Case Note from the drop-down menu.
Once Case Note is selected, click the play button.
Add the date, a title, and enter the note details.
Select Save As Draft to complete the case note at a later time. You can preview the note to check for accuracy or finalize the case note to add it to the case.
- Currently, the Forward Case Note functionality does not work.
- Case notes can only be removed while in draft mode; once finalized, it cannot be removed/deleted. The only exception is PDF Flowsheets (a permanent version is kept in the flowsheet section of the chart). You can, however, make an addendum to make changes to a case note.