The clinician builds a patient note by simply selecting, through drag-and-drop, the high-level outline of the note. The outline of the note can be problem-based, system based, or in any other format preferred by the practitioner. Based on the outline topics selected, NNM automatically retrieves the appropriate clinical data for inclusion on the note. Additional comments can be added through drag-and-drop selections of frequently-used comments that are specific to the individual practitioner and the current outline topic.
Previous notes can be copied and used as a basis for a current note. In addition, user-defined templates can be used to automatically generate a note outline, or re-arrange an existing note outline. The copy function and use of templates make it even faster to develop a comprehensive note.
A variety of note types can be generated. For example, an Admission Note can be generated where infant demographic and maternal history are automatically retrieved along with text relating to admission procedures. Other note types include Medical Progress Notes, Nursing Progress Notes, Consult Notes, Procedure Notes and Discharge Summaries.
When creating a Discharge Summary, the clinician can direct NNM to review the clinical data from the entire stay and summarize key points such as diagnoses, medications, oxygen therapy and referrals. Also, during the course of the stay, the clinician can mark comments made in daily progress notes as "discharge comments". These comments can be automatically retrieved and copied into a discharge summary. The end result is that most of the Discharge Summary is automatically created from the clinical data and note comments that were entered during the course of the stay.
Notes can be written and edited by any authorized staff member. When the note is complete it is "signed" by the staff member. When signed, all text on the note is frozen and cannot be changed or deleted.
Notes can be created by one staff member and reviewed, updated and signed by a different, higher-level staff member.
The final note can be reviewed and printed as a single note, printed as part of a notes log for that patient, or printed as a batch of signed notes for a particular staff member.