Signed clinical documents that are in the patient chart can have information added to the note by completing an addendum. It may be an additional piece of information that was given after the document was signed, a mistake in documentation that needs to be corrected or clarified, or other information that needs to be added to the documentation.
To add an addendum follow these steps:
- Open the Patient Chart
- Click Documents from the patient char navigation menu
- Find the document that needs the addendum and click the Action drop-down
- Click Add Addendum button
- Next select the document type and add any participants if necessary. Click Ok
This will open the Addendum and allow a user to complete the following tabs:
- Content tab: that presents a word processor text box for content to be input.
- Details tab: where information about the appointment can be edited. Name of the addendum, date, and time can be edited
- Medications tab: show any current medications or medication changes completed by the note. While this cannot be edited in the addendum, this section is available for review
- Diagnosis tab: All diagnosis that are active after the note is signed. This tab is read only and cannot be edited.
- Click Sign and Close to complete the addendum.
Clinical Notes that have an addendum attached will have a red letter A next to the document name.