Primary Care Note

Primary Care Note

Index

  • Sections
    • Primary Care Note
    • Creating a Primary Care Note

Primary Care Note

A Security Administrator can request to have the Primary Care Note enabled by emailing ticket@icanotes.com. For primary care providers who will be utilizing auto coding for e/m coding, please refer to this knowledge base article. 

Creating a Primary Care Note

1.  Click the Primary Care button at the bottom of the patient's Chart Face.

Screenshot for Primary Care Note

Screenshot for Primary Care Note

Screenshot for Primary Care Note

Screenshot for Primary Care Note

Screenshot for Primary Care Note

2.  Throughout the program, buttons are organized in a clinically logical format. Begin your button selection by moving from top to bottom in the left gray column. Start by clicking the Chief Complaint button and typing the patient's chief complaint after the populated text. 

Screenshot for Primary Care Note

3.  Click the Screenshot for Primary Care Note button to document history of risk factors, current risk factors, protective factors, and other suicide/violence related factors, as needed. Simply click on a shrub to expand further options to the right. Once you're finished, click Screenshot for Primary Care Note in the upper-left or lower-right to navigate back to the main Primary Care Note window. 

4.  Click the Screenshot for Primary Care Note button to chart your physical exam with the patient. 

5.  If a patient has no other complaints, you may click one of the 'ALL NORMAL' shrubs and then edit the populated text in the yellow field accordingly. 

6.  You can use the other shrubs to add more specific information or create the physical exam from scratch. The example below shows shrubs that were sequentially clicked to indicate that:

  • There is a neurological abnormality  
  • The abnormality is related to tremors
  • All cranial nerves were checked

7.  You can document OBGYN and Prostate Exams in Primary Care Notes by clicking Screenshot for Primary Care Note and <img src="https://app.teamsupport.com/dc/622114/attachments/72a9f538-9725-4651-b8f7-9bf40f58dbdc

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