Ownership of Notes

Ownership of Notes Authored by Trainees

Notes authored by Trainees (resident/fellow) in the outpatient setting will be "owned" by the trainee, even after cosigning, editing, or attestation.

Cosign Other clinicians can see the note before it is cosigned, the status of Cosign Needed is shown. After it is cosigned by a supervising provider, the student appears as the author and the attending appears in the revision history.

Attest Supervising providers can add attestations directly to a trainee's note and the attestation verifies the note's content without having the provider take ownership of the note.

Edit Supervising providers can edit a note, the edit will not be identified in the same way that an attestation is but, edits are tracked and are displayed in the note revision history.

Addend After the note is signed, or cosigned, the text of the note can be Addended (updated). Addended text will not stand out in the same way that attestation will but, but edits are tracked and display in the note revision history

Routing notes as a Consult Letter

Outpatient notes are by default progress notes that do not leave the system. When outpatient visit is for a consult the Communication function is used to route that note to Netcare and/or to other providers.

When your note is used to create the Consult Letter you will appear as the note author in Netcare, not the supervising physician the patient is scheduled with.

Creating a new note "owned" by the Supervising Physician

If your staff wants to use your note for the consult letter they can:

- Create a copy of your note, or make themselves the author of your note, then Use the Communication function to route the note to Netcare and selected recipients.

Copy and Create New Note

Click edit on the note authored by the trainee
At the bottom left of the note is an icon that looks like two overlapping pieces of paper
This button will copy the note text and create a new note with the supervising physician as the author
Add to the note as necessary
Accept the note
Make sure to select Send to PCP & referring, or use the Communication tool in the Wrap Up activity to have a Consult Letter sent to Netcare
Once the visit is signed the letter will be routed to Netcare and the selected recipients
The author of the note will be the supervising physician.

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