Adding a document to a patient record

Estimated reading: 22 minutes

Learn how to fill out medical notes and correspondence documents to be added to the patient record and/or printed/emailed. In addition, learn how to add addendums to finalized documents and void documents.

Before you start

Security

Setup

Important!

  • Enter the Staff ID for the staff responsible for the entry. The staff ID will display with the document in patient history.
  • A client, patient and active staff ID are needed to start a document. Once saved, only the staff ID can be changed until the document is finalized.
  • Ensure you understand each of the document template types.
  • Addendums and voided documents cannot be removed or edited.

Add a medical note to a patient

Navigate to the document window

  1. Start a document from Patient Clipboard > right-click the patient’s name.
  2. Select Correspondence or Medical Notes depending on the document template type needed.
  3. Do one of the following based on your document settings:
    • Select a template from the favorite document submenu and enter the Staff ID for the staff responsible for the entry. The Cornerstone Editor window opens.
    • Select All Medical Notes to access all active document templates from the Start New Document window.
    • Select a document template from the Start New Document window.

Learn other ways to navigate to the Start New Document window in Additional Information.

Start new document window

The Start New Document window is used to search and select a document template, except for these situations:

  • Selecting from favorite document submenus on the Patient Clipboard.
  • Checking in a patient with check-in documents attached.

Some fields may already be populated, depending on how the window was accessed.

The window displays all active document templates in Title order. Correspondence or Medical Note type will be preselected, based on how the window was accessed.

  1. Do any of these from the Client ID field if not already populated:
    • Click the drop-down to select a recently accessed client.
    • Enter the client ID and press the tab key.
    • Press F2, or double-click to search for and select the client from the Client List.
  2. In the Patient ID field, enter the Patient ID or use F2 to search and select from the Patient List, if not already populated.
  3. Enter the Staff ID or F2 to search and select from the staff list.
  4. Search and select a template by doing any of the following:
    • Enter a key word or a document ID.
      Note: Verify Search for Word is selected.
    • Narrow results by selecting a Category or Favorites. Favorites are set in staff and document defaults.
    • Uncheck or select template type checkboxes, as needed.
    • LifeLearn® users only: Use LifeLearn search area to search by keyword, species, topic, and/or system.
  5. Sort the list by any of the columns, by clicking the applicable column header.
  6. The selected template will display in the preview pane at bottom of window.
    Note: LifeLearn® and MS Word® document previews will not display.
  7. Double-click the template or select it, and click OK to begin the document in the Cornerstone Editor.

Cornerstone Editor

These are the overall steps for filling out a patient document. Depending on the document type, defaults set, and template elements, any of the following may need to be completed

  1. Enter any information you are prompted for:
    • Patient weight: Enter your staff ID, the patient’s weight and click OK. Click Cancel to exit the window without entering a weight.
    • Question/Answer bookmarks: Enter information as prompted in the associated pop-up boxes.
    • Medical history bookmarks: Select/enter information as prompted in the associated pop-up boxes. Example: Departing instructions.
    • Staff Signature bookmark: This requires a staff signature be setup. Go to Lists > Staff > Signature tab.
    • Pick or Group items: Choose the applicable items.
  2. Any other included bookmark information is automatically pulled into the document.
  3. Fill out the body of the document, based on how the document template is setup:
    • Free Type
    • Text input
      • Tab and type into Text Input fields, with the Lock feature enabled.
        • Click the Lock/Unlock document button on the Cornerstone Editor toolbar.
        • Click into the first field, if needed to begin Tab through.
      • Double-click within field to type your entry when not using lock/TAB.
      • Tab through any fields containing initial data that does not need to be modified.
      • To insert a new line within a Text Input Field, press the Shift key + Enter.
      • To go back to a previous Text Input Field, press the Shift key + Tab.
  4. Add additional elements as needed.
  5. Save or complete and finalize the document. Update status or client signature.

Collect and insert weight/Vital Signs

Weight and vital signs can be easily recorded and inserted within the body of the document during the document process.  

  1. To record weight and/or vital signs only, do one of the following: 
    • When opening a medical note, a weight entry prompt may appear, based on document default settings.
      • Enter the weight and click OK.
      • Click Add more Vital Signs link, if needed, to enter additional information. 
    • In the document banner, click the Vital/Signs/Weight icon.
      • Enter the weight and click OK.
      • Click Add more Vital Signs link, if needed, to enter additional information.
  2. To record (and insert) up to five weight and/or vital signs set(s) into the document, do one of the following: 
    • Click Add Vital Signs information prompt within body of the document. 
    • If prompt link not present, click within body of document to set where the information will appear: Insert menu > Vital Signs or right-click > Insert Vital Signs 

  3. Record the information in the Vital Signs window and click OK.
  4. Select up to 5 data sets to include and click OK.
  5. Select or enter the recording staff name and click OK.
  6. Click OK to insert the information table into your document. 
  7. To insert (and record) a single weight only:
    • Click within body of document to set where the information will display: Insert menu > Patient Weight or right-click > Insert > Patient Weight.  
    • Enter a new weight and click OK or click Cancel to use the last recorded weight.  
    • The weight, unit and date are inserted. 

Add a problem or diagnosis

Existing and new problems and diagnosis can be added to a document using the associated patient history and lists.

  1. Do one of the following:
    • Click the corresponding information prompt link inside the document: Add Problem Description, Add Problem Details or Add Diagnosis Description, Add Diagnosis Details
    • If prompt link is not present, Click within body of document to set where the information will appear doing one of the following.
      • Insert menu > Problem Description, Problem Details or Diagnosis Description, Diagnosis Details.
      • Right-click > Insert Problem Description, Insert Problem Details or Insert Diagnosis Description, Insert Diagnosis Details.
  2. The patient’s existing information displays. Do any of the following:
    • Click Add to Document for each existing entry to appear in the document.
    • Enter ID or F2 to search and select from the associated code list. Based on security access, you can also click New to create a code if it cannot be found. Adjust details as needed (date, status/state, staff).
  3. Click OK when finished selecting/adding codes.
  4. The selected description(s) are added to the document. If multiple descriptions are added, they display separated by commas.

Annotate images

Make annotations to an image or picture that is part of the template (ex: medical illustration).

  1. Double-click on the image.
  2. Use Image Viewer tools to make annotations and edit the image as desired.
  3. When finished, click the X button in the top right corner of the window.
  4. Click Yes to save changes. The edited image is displayed in your document.

Insert additional images

Add images to your document as needed, using either:

  • the Imaging bookmark, for images imported into patient history
  • folder location on your workstation/network
  1. Click within body of document to set where the image will appear.
  2. Insert the imaging bookmark or obtain image from a folder location via:
    • Insert menu > Picture or Picture and Description or
    • right-click > Insert > Picture or Picture and Description
  3. Navigate to the folder/device location and select the image file: jpg, tif or bmp file type.
  4. Click Open.
  5. The image is added to the document. If using Picture and Description, the image is placed in a two-cell table with the image in the left cell and the right cell can be used for notes.

Insert additional bookmarks

  1. Click within body of document to set where the bookmark information will appear.
  2. Insert by:
    • Clicking Editor’s Bookmark toolbar button
    • Insert menu > Bookmark.
    • Right-click > Insert > Bookmark.
  3. Choose the bookmark from File and Field Description dropdown lists.
  4. If prompted, select the format for date bookmarks.
  5. Click Add Bookmark
  6. For each additional bookmark:
    • Leave the bookmark window open.
    • Click within document and repeat steps 3-5.
  7. Click Close to close the Select Bookmark window.

Add Attachments

Add file or web page attachments to the document by clicking the Attachments tab in the pane at bottom of window. Attachments will display with in patient history.

  1. Add file attachment(s) by clicking New File.
    • Navigate to the appropriate folder to select file(s). Use Ctrl + Click for selecting multiple files from the same folder and click Open.
    • Repeat as needed for additional files in other folders.
  2. Add webpage link by clicking New URL.
    • Navigate to the desired webpage.
    • Copy the web address and then click Paste URL.
  3. Remove attachments by selecting the file name and click Delete.
  4. View attachments by double clicking the file name. You need the appropriate program available to view the file.
    • Includes standard file types such as doc, docx, PDF, txt, xlxs, csv, etc.
    • Supported media file types: .bmp, .jpg, . jpeg, .jp2, .png, .tif, .tiff, .avi, .mpg, .mpeg.

Update/add invoice items

Update the status of included items and/or add invoice items to send to the Patient Visit List (PVL), when the document is saved.

Statuses are the same ones used on the Patient Visit List (PVL): Recommended, Accepted, Performed, Declined, Declined to History. The items are retained on the document template, but not included in the body of text. See Additional Notes. for more details.

  1. Update included invoice item statuses to send to PVL by clicking the Stat field button.
  2. Add additional items as needed, completing information for the item row, and then set the status.
  3. Remove items as needed by clicking in the Item ID field and press the ctrl key + D.

Capture client signature

Using either an approved connected device or touchscreen Cornerstone workstation, add a client signature to a document. Example:

A Client Signature bookmark is required in the document template.

  1. When your document is complete and ready to be signed by the client, do one of the following: 
  2. Click the Client Signature button on the Editor toolbar.
     
  3. Add the bookmark if not present (signature button disabled): 
    • Click within body of document to set where the bookmark information will appear. 
      • Insert by clicking Editor’s Bookmark toolbar button, Insert menu > Bookmark or right-click > Insert > Bookmark 
      • Select Client from File Description. 
      • Select Client Signature from Field Description 
      • Click Add Bookmark 
  4. Click the Client Signature button on the Editor toolbar.

Using a touch screen enabled Cornerstone workstation or approved attached external device, have your client sign in the Client Signature field. 

  1. Click Clear/Reset if needed to recapture the signature.
  2.  Click OK to accept the signature. Once signed, the document is automatically finalized and you are prompted to print the document.
  3. Click OK to print or click Cancel

Editor window display options and functions

Display Options

Banner and editor functions

Saving a document

  1. When finished and ready to save the document, select the appropriate status: 
    • Draft: The document is still in progress and the notes are not verified or finished. Any invoice items are saved in their current state, without sending anything to the Patient Visit List. The document will not be auto-finalized, even if it is selected.  
    • Tentative: The document is still in progress, and changes can continue to be made. Invoice items are sent to the Patient Visit List in their current state (highlighted green). If using auto-finalize, the document will close in the established time frame. 
    • Final:  No further edits can be made. Additional information can only be added in an Addendum. When saving as Final, the Apply to PVL check box is preselected and cannot be cleared. Any invoice items are sent to the Patient Visit List in their current state (highlighted green). 
  2. Do one of the following:  
    • Click OK to save the document and close the Cornerstone Editor. 
    • Click Save to save the document and continue working in the Cornerstone Editor. If the document is set to final, the document window will close.
    • Click Cancel to cancel document changes and close the document. 

Add an addendum to a finalized document

  1. Navigate by either:
    • Patient Clipboard > Summary, Text or Medical Notes tab > double-click document (final or closed) > Addendum.
  2. Enter your staff ID and press the tab key.
  3. Enter the addendum notes.
  4. Click OK.
  5. Click Yes or No on the confirmation message.

    The addendum is added to the document. In addition, “***ADDENDUM [addendum date]” is added to the document’s line in patient history.

Void a patient document

  1. Navigate by either:
    • Patient Clipboard > Summary, Text or Medical Notes tab > double-click document > Void.
    • Daily Planner > medical Notes or Correspondence tabs > double-click document > Void.
  2. Enter your staff ID and press the Tab key.
  3. Enter a reason for the void.
  4. Click OK.
  5. Click Yes or No on the confirmation message.

Notes:

  • A voided document is marked with a “VOID” watermark when viewing or printing the document.
  • The document is also hidden in patient history when the Patient Clipboard’s Hide voided items check box is selected.

Additional information

General

Staff ID

Patient weight

Patient problems and diagnosis

Document status and saving

Text only document templates

Text input fields

Signatures

Images/annotations

Attachments

Invoice items

Navigate to the Start New Document window

Merge Cornerstone data with a document

Void a document

Related Reports

  • Patient Documents Finalized by EOD
  • Tentative Medical Note report
  • Voided Documents report

Resources

Check out our Professional Services Catalog for additional courses on electronic medical notes, going chartless and other course offerings!

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