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How to Document Phone Calls / Internal notes/View Audit Logs
DocVilla EHR allows providers and staff to document patient-related phone calls for accurate recordkeeping. Phone call notes can be added directly to the patient’s profile and also viewed within encounters.
Internal notes should not be used as a replacement for an actual consult or encounter.
Internal notes, including documentation related to phone calls, are intended for internal documentation purposes only. They are not a substitute for a patient encounter, cannot be billed as an encounter, and cannot replace an encounter for audit purposes.
Internal notes, including general notes, phone notes, and sticky notes, are strictly for the practice’s internal general-purpose use only. They do not become part of the clinical documentation, such as Encounter SOAP notes.
Documenting a Phone Call
Go to the Patients tab at the top.
Search for and select the patient’s name.
Once the patient profile opens, click on Add Note.
Fill in the details:
Subject – Enter a subject line for the note.
Note Type – Select Phone Call.
Description – Enter the details of the call.
Click Save Note to save the record.
Viewing Notes Within an Encounter
Go to the Consults tab at the top.
Search for and select the patient’s name.
Click on the icon labeled See Patient Notes to view all notes (including phone call notes) linked to the encounter.
How to View Audit Logs
Audit Logs allow practices to track changes made within a patient's record, including who made the changes and when they were made. This can be helpful for internal tracking, compliance, and troubleshooting purposes.
Steps to View Audit Logs
Go to the Patients tab at the top of the dashboard.
Search for and select the patient's name.
Once the patient profile opens, click on the search icon labeled "View Audit Logs for this Patient."
In the Audit Log Type dropdown, select "Patient Notes."
Review the audit log entries displayed on the screen.
Important Note
If you would like to internally track which staff member made specific changes and when those changes occurred, you may refer to the Audit Logs for a detailed history of activity within the patient's chart.
What Information Gets Printed on an Internal Note?
When printing a phone call or internal note, the system includes certain details by default. Additional information can be included by updating the note before printing.
How to Edit an Internal Note Before Printing
Go to the Patients tab at the top.
Search for and select the patient's name.
Locate the note and click the pencil icon next to it to edit the note.
Make the necessary updates.
Click Save to save your changes.
To Print the note, Select the note, and click on 'Print'.
What Information Is Printed?
When a phone encounter or internal note is printed, the system automatically includes:
The date the phone call or note was created
The staff member who handled or documented the interaction
If you would like additional information to appear on the printed document, enter that information in the Description field of the note before printing. Any content entered in the Description section will be included in the printed output.