Quick Add simultaneously adds an item (diagnosis, rx, charge, etc.) to the text of your note AND as a formal coded entry to the relevant encounter note block (Assessment, Plan, Charges) and/or, if applicable, to the relevant part of the patient's chart (Medications or Supplements List, Vaccine Chart, Preferred Facilities). Like Chart Parts, Quick Add is accessed simply by typing in the main text area of an open encounter note, enabling you to quickly search for and add any item from certain databases (diagnoses, orders, prescriptions, vaccines, charges, alternate plan items, and facilities). And it saves time when you want information about the item to go in the text of the note AND be entered as a formal, coded entry.
To search the database for the entry you would like to add, first type the applicable two-letter prefix (see table, below, this which tells the system which database to search), followed by an underscore.
Immediately after the prefix and underscore, type in one or more search terms, separating multiple search terms with underscores, not spaces (a space ends the search). Once you've typed in the prefix, underscore, and at least three characters, the system will display potential matches to the left of the main text block.
Select an entry using your mouse or, to select an entry from the list without using the mouse, press the up arrow to select and add the topmost entry or toggle to the list by pressing the left, right, or down arrows on the keyboard. Within the list, the down (or right) arrow moves down the list, and the up (or left) arrow move up. Press enter to select.
This will add information about the selected entry to the main text block, and add a Suggested Action above the Assessment block on the right hand side of the note. Click on a Suggested Action to take that action (adding the item to the Assessment, Plan, or Charges section of the note and/or updating the relevant part of the patient's chart), or click on the red x to dismiss.
So, for example, you could type or_cbc and select the suggestion "CBC complete blood count, automated" to add the name of the order to the text of the note and create a Suggested Action to add a CBC order to the Plan of the note (and the patient's Open Orders).
Quick Add Prefixes
|Category||Prefix||Search By||What Happens when you Select an Entry?|
|Actions||dx_ = diagnosis||Diagnostic name, nickname(s), ICD-9 code||- Text added to main text block: diagnosis name and CPT code|
- Suggested action: diagnosis
Accepting the suggested action (by clicking on it) adds the diagnosis to the note's Assessment block.
or_ = order
xr_ = order (x-ray)
|Title, subtitle, category, nickname, description||- Text added to main text block: order title|
- Suggested action: order
Accepting the suggested action (by clicking on it) adds the order to the note's Plan block and pops up the Add/Schedule Orders" dialogue.
|rx_ = drug||Drug name, brand, ingredients, strength, delivery method, form||- Text added to main text block: drug name|
- Suggested action: prescription
Accepting the suggested action (by clicking on it) adds the prescription to the note's Plan block and pops up a "+ Complete and Add Rx" dialogue.
|vc_ = vaccine||Name, nickname(s), brand||- Text added to main text block: vaccine name|
- Suggested action: vaccine
Accepting the suggested action (by clicking on it) adds the vaccine to the Plan block and pops up an "+ Add New Vaccination" dialogue. The vaccine will be entered into the next open dosing for that vaccine in the patient's vaccine chart.
|ch_ = charge||Name, nickname(s), CPT code||- Text added to main text block: charge name|
- Suggested action: charge
Accepting the suggested action (by clicking on it) adds the charge to the note's Charges block.
ap_ = alternate plan item
|Name, nickname(s)||- Text added to main text block: alternate plan item name|
- Suggested action: alternate plan action (e.g., supplement prescription, recommendation, etc.)
Accepting the suggested action (by clicking on it) adds the alternate plan item to the note's Plan block and pops up a "+ Complete and Add [Alternate Plan Item]" dialogue.
|Facilities||lb_ = laboratory||Name, street address, city, state/province, postal code, phone number||- Text added to main text block: facility/specialist name, address, phone number|
|ph_ = pharmacy|
|sp_ = specialist|
rd_ = radiologist