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How to enter data into progress note chart

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Entering data into progress note chart #

There are four ways using which data can be entered into the progress note chart:

  • Dot phrases
  • Text entry
  • AI Assistant
  • Transcribe

To enter the data:

  • Open the patient profile
  • Go to EMR
  • From Summary, open the progress note you want to work on

Using dot phrases #

To use dot phrases

  • Click under the heading that you’re working on
    • A text field is displayed
  • Type a dot (.) in the text field
  • A drop-down menu with a list of dot phrases is displayed
  • Type in the word that you’re looking for to prune the dot phrases or scroll through the dot phrase list
  • Click on the option that you want to add 

 

Text Entry #

To add data in chart using text entry

  • Go to progress note chart
  • Click under the heading you want to work on
  • A text field is displayed
  • Type in the text
  • Clicking anywhere on the chart will save the data you entered

Using AI in EMR Progress note #

Legend EHR incorporates AI in the EMR progress notes.

  • It uses two different AI models to populate the patient chart
  • Clinicians can document using either dictation or natural conversation
  • AI automatically segments and organizes your input into structured notes
  • Context-aware technology fills in fields like PMH, HPI, and A&P

AI Assistant #

To enter data using AI Assistant module,

  • Go to progress note chart
  • Click on the AI Assistant button
  • The interface in the image below will open

Record button #

  • Click on the Record button and start dictating or conversing with the patient
  • When you start speaking, AI will listen and populate your auditory input in the window above

Stop button #

  • If you want to pause, you can click on the Stop button

Edit text #

  • If you want to edit the text that AI populated, click on the Edit text button
  • Click on the Stop editing button once you have finished editing

Clear #

  • If you’re not satisfied with the output that AI has generated based on your speech, you can erase it by clicking on the Clear button
  • Clear button will erase all the text generated by AI in the window above

Process and Send #

  • Once you are finished conversing with the patient or dictating to AI, click the Process and Send button
  • Legend will send your speech data to the AI models
  • Wait for a few second

In a few seconds, you’ll be redirected to the progress note chart where you’ll be able to see the data AI has populated based on your speech input

Using Transcribe #

Transcribe is an AI language model that listens to the conversation between provider and patient and populates data in the chart based on the conversation. To add data using Transcribe

  • Go to progress note chart
  • Click on the Transcribe button
  • Click on Start Recording

 

  • Start conversing with the patient
  • If you want to pause, click on Pause Recording button
  • When you are done, click on close button ‘x’
  • AI will populate data in the chart

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