1. OpenEMR: Patient Notes & Transactions Based on OpenEMR 4.1 Laboratory Informatics Institute January 2014

2. OpenEMR: Patient Notes & Transactions Patient Notes Transactions: Referrals Transactions: Basic

3. OpenEMR: Patient Notes & Transactions Patient notes contain information not related to the patient medical condition. Things like outstanding balances, changes in insurance, patient requests from the clinic. Transactions record events that have already occurred. Legal transactions, requests from the doctor, or the patient.

4. OpenEMR: Patient Notes & Transactions To add a patient note: login to OpenEMR and find the patient you wish to add the note to. Remember you can search for patients, using the function in the lower left corner. Click on the desired patient’s name to be taken to their summary page. Unauthorized users will not be able to see information on immunizations, prescriptions, or medical conditions for the patient.

5. OpenEMR: Patient Notes & Transactions Click edit next to the notes section, and then select add. This will present a drop down menu for the type of note and the addressee of the note. Type the note in the text box and then save it, by clicking save as new. The check box is used to mark a note as active. Click on sent items to view previous notes, or view patient to return to the summary.

6. OpenEMR: Patient Notes & Transactions Clicking transactions at the top of the summary page will take you to the patient transaction page. Transactions contains a page for internal transactions: billing and requests. Transactions contains a page for referrals. Click add and select referral to begin the referral process.

7. OpenEMR: Patient Notes & Transactions Use the drop down menu to select the physician you wish to refer the patient to and additional information, such as risk level. Click save to save the referral to the patient transaction page. Click print to generate a copy of the referral form. Your system may also ask you to save the file.

8. OpenEMR: Patient Notes & Transactions When you are finished, return to the transaction list and click add. Non-Referral transactions use the simple transaction form. Select the type of transaction from the drop down menu. Enter the details in the text box. Select save.

9. OpenEMR: Patient Notes & Transactions Click edit next to the transaction to edit the contents as needed. Note that both the referral and the basic transaction are now showing on the transaction list for the patient.