Which tabs are available in NoteWriter for documenting patient notes?

The selection of HPI (History of Present Illness), ROS (Review of Systems), physical exam, and MDM (Medical Decision Making) represents the core components of patient documentation in the emergency department setting. Each of these sections serves distinct purposes:

• HPI provides a detailed narrative of the patient's current condition as described by them, which is crucial for accurate diagnosis and treatment planning.

• ROS includes a systematic review of various body systems to identify any additional symptoms or issues that may inform care.

• The physical exam section offers objective findings that contribute to the assessment of the patient's health status.

• MDM outlines the clinical reasoning behind diagnosis, treatment choices, and care strategies based on the information gathered in the HPI, ROS, and physical examination.

By utilizing these specific tabs in NoteWriter, healthcare providers can ensure comprehensive and organized documentation, facilitating effective communication within the care team and supporting quality patient care. This structured approach also aids in meeting legal and regulatory documentation standards.