Progress notes can be entered in the standard SOAP format or they can be entered all on one page on the Interval page.
Standard Soap Note Format
As one can see, various portions of the note can be entered in each of the
tabbed sections which include Subjective, Objective, Assessment, Plan,
Vitals, Rx and Education. Each of these sections contains an HTML editor
so that the note be written with different types, sizes and colors of
fonts, the background color can be chosen, the text can be bolded and
underlined and the position on the page can be determined.
These notes can be printed only through the browser print mechanism
Interval Note Format
In this format, the note is written on one page. HTML formatting is not
included so that the note can be entered with voice dictation. Notes
entered here can be printed as a nicely formatted PDF file using the
FreeMED print button found just to the right of the progress note
description.
On the Basic Information page, one can choose to use a template to create the major portion of the note.
Template Creation: To create a new template, click on "Add" next to the sentence "Progress Notes Template". This will take you
to a new screen where you can enter the name of the template, enter the note in the various categories and then click on "Modify".
If at a later date, one wants to change the template, just click on the "Edit" button.
The best way to remove a template is to rename it "z", erase all of the fields and then click on "Modify".
To use a template, choose the name of the desired template and then click the "Use" button. This enters the templates into the fields
of the note. Then click on the tabs where you might want to enter changes to complete the note.
Once the note has been created, enter the name of the provider, the initals of the typist (if desired), the description of the note and the
related episodes (if desired). Then click on "Add" on the bottom of the page to add the note.
If one is using the Progress Note Box module, then one can enter scanned of faxed progress notes here. This is useful if a patient is seen in
the office and then later is seen in an extended care facility. The notes from the extended care facility can be faxed directly into FreeMED
and added as a progress note.
To add a Superbill notification to the Billing Department, click on the
Superbill tab. Choose the procedure from CPT codes that you have entered or
click on the + sympol to enter a new CPT code.
After you have chosen the CPT code, click on Add Procedure.
Now choose the diagnosis from the ICD 9 codes that you have entered previously
or click on the + sympol to enter a new ICD 9 code.
After you have chosen the ICD 9 code, click on Add Procedure.
Now click on Add to create the Superbill notification.