This article walks you through the various options you have to close out your note and move on to the next step of your clinical workflow when ready to leave the chart note. OptiMantra provides multiple flexible ways to complete your note, allowing you to choose the method that best fits your workflow and documentation preferences.
Closing & Finalizing Your Chart Note
Adding a Type & Tag
If you haven’t already done so, we always recommend adding a type (found in the upper grey toolbar) and a charting tag (found at the bottom of your note). These will help you classify and review your charting while looking at the patient's charting history.
Checkboxes
The checkbox options found at the bottom are meant to be paired with the clickable buttons so you can complete two actions at once. For example you can “Sign & Lock Consult” and “Save Consult & Create Superbill” to fully lock your chart note and go directly to your superbill to check out the patient
Save & Close
Save & Close will save your note and bring you back to the scheduling home page.
Save
Save will save your note but keep you in the chart note.
Lock & Sign Consult
Lock & Sign will digitally sign and lock your note preventing further edits and bring you back to the scheduling home page or previous page you were on prior to opening the note.
Sign Consult
Sign Consult will digitally sign your note and bring you back to the scheduling home page.
Save Consult & Create HCFA
Save Consult & Create HCFA will save your note and bring you directly into a HCFA form to prepare your insurance claim. This method will pull in the ICD’s and CPTs or Services from your Assessment section directly into the HCFA form.
Save Consult & Create Superbill
Save Consult & Create Superbill will save your note and bring you directly into a Superbill to check out the patient or send them an invoice. This method will pull in the ICD’s and CPTs or Services from your Assessment section, as well as the inventory added into the plan section, directly into the superbill.
Viewing & Editing Charts
Once you have closed your note you have the ability to review it in the patient's charting history, add an addendum, or fully unlock the note if needed.
- View the patients charting history by selecting the patient’s actions menu and navigating to “charting history” found in the middle row.
- View a full list of your open charts by going to shortcuts > view open charts.
- Follow the steps in our knowledge base here to add an addendum or unlock a note.