Using the Short Form Nurse Note

The Short Form Nurse Note is a standard form that can be used to begin a Progress Note. It allows staff to quickly enter patient history, vitals, medications, and allergies, and when finished, adds the recorded information on a new note for the patient that a Provider can then choose to continue documentation on.  

Below, we’ll review how to access this feature, how to complete the form, and where the information appears once saved.

Before We Begin

The Short Form Nurse Note automatically creates a new progress note as soon as it is opened—even if no information is entered. This page has no required fields, so only complete the sections necessary for your workflow.

Steps to Use the Short Form Nurse Note

1. Open the Short Form Nurse Note

• Navigate to the patient’s chart.

• Hover over Progress Notes in the top menu.

• Under Add System Progress Note/Encounter, select Short Form Nurse Note.

• The SOAP-style layout for the nurse note will open, and a new progress note will be created for the patient.

2. Enter Encounter Information

• At the top of the page, review or update:

• Encounter Date (defaults to today)

• Encounter Type

• Office

• Provider

• Location of Service

• Reason for Visit

3. Record Smoking History

• Use the drop-down fields to select:

• Smoking frequency

• Start and end dates

• Other relevant smoking details

4. Document Advanced Directive

• Use the drop-down to record the patient’s Advanced Directive.

• Enter the date it was last reviewed.

5. Enter Vital Signs

• All vital sign types supported by the EHR will be available.

• Add only the vitals needed for the encounter.

6. Add Allergy Information

• Select one of the following:

• Unknown

• No Known Allergies (NKA)

• Patient Has Allergies

• If allergies are present, additional tools will appear:

• Allergy Search button

• User Allergy List (the “…” ellipsis button)

• Add Free Text Allergy link

• Enter any relevant notes in the allergy note field.

7. Add Current Medications

• Use the Drug Search/Select button to locate medications.

• Use the User Defined Medication List via the ellipsis (…) button if needed.

• You may also:

• Add free-text medications

• Enter medication-related notes

8. Add the Nurse Note

• At the bottom of the page, enter details relevant to the visit in the Nurse Note text field.

9. Save the Note

• Click Update to save.

• The note will now appear as a regular progress note and can be accessed from:

• View Progress Note/Encounter

• Patient Summary Page

Viewing and Printing the Nurse Note Later

1. Edit the Progress Note

• When editing the note in the future, it will load using the default layout assigned to the user in the Manage Office tab.

2. Locate the Original Nurse Note

• While editing, look at the History Panel on the left side.

• Click Nurse’s Note to view the text entered during the Short Form Nurse Note.

3. Print the Nurse Note (If needed)

• In the History Panel, expand Note Properties.

• Select Print Nurse’s Note (if one exists) to include it when printing the progress note.

‍