Welcome to NFH

This is your progress note — the digital equivalent of the patient's paper chart for that appointment. This is where the clinician documents the HPI, vitals, diagnosis, and any treatment plan (labs, prescriptions, or referrals).

How to Navigate: The progress note is organized into sections, each accessible by clicking blue hyperlinks on the left side of the screen:

• Chief Complaint / HPI (History of Present Illness)
• Current Medications
• Medical History & Allergies
• Social History, Family History, Surgical History
• Vitals
• Examination
• Assessment (Diagnoses)
• Treatment (Orders & Plan)
• Immunizations

Once you open a section, you can navigate to other sections using the picture icons at the top of the screen. Hover over each icon to see which section it represents.

When you open a patient's chart, the Patient Dashboard gives you a quick overview of their key information. Think of it as a summary hub before diving into the detailed progress note.

On the right side of the progress note screen is the Right Chart Panel — one of the most efficient tools in eCW for quickly reviewing patient info without leaving the progress note. It has three tabs:

Overview Tab — A snapshot of the patient's ongoing medical picture:

• Problem List: Chronic conditions already diagnosed. Blue arrows move a diagnosis into today's note.
• Current Medications: Everything the patient is supposed to be taking.
• Allergies: Known drug and other allergies.
• Immunizations: Vaccination history (click + to expand).
• Therapeutic Injections: Ongoing injection therapies.

DRTLA Tab — Documents, Referrals, Telephone Encounters, Labs, and Actions:

• Lab orders and results — pink paperclips = electronic result received
• Diagnostic Imaging orders and results
• Referral history — click the reason to see specialty details

History Tab — All background histories in one place: Medical, GYN, Surgical, Family, and Social History.

Test results can be found in three places within eCW. If you're asked to locate a result, check them in this order:

Understanding the typical charting workflow helps you follow along as the clinician documents during a patient encounter:

HPI (History of Present Illness)

This is where the clinician documents the patient's reason for the visit in their own clinical words:

• Notes Box: Click "Notes" next to a complaint to open a free-text box — this is the "Subjective" of the SOAP note.
• Structured Data: Some HPI questions have drop-down menus for standardized answers, plus free-text alongside.
• Clinician HPI: If no mini-template appears, the clinician navigates to "Clinician HPI" on the left for additional questions.

Review & Revise Sections

The nurse/MA completes these before the clinician sees the patient. The clinician reviews and revises as needed:

• Current Medication (nurse does reconciliation first)
• Medical History & Allergies (mark NKDA if applicable)
• GYN History (female patients — via blue hyperlink)
• Surgical & Hospitalization History
• Family History
• Social History — two folders: General, and Tobacco/Alcohol/Drugs
• Vitals — recorded by nurse/MA, reviewed by clinician

Examination

• Green Arrows: Click to populate the default "normal" observation — speeds up documentation for unremarkable findings.
• Free-Text: Click into the Observation field to type custom notes for abnormal or notable findings.

Assessments (Diagnoses)

Every treatment order must be linked to a diagnosis. The Assessment screen is where ICD-10 codes are entered:

• Previous Assessments: Click to see diagnoses from prior visits. Single-click to select.
• Problem List: Pull diagnoses from the patient's chronic conditions list.
• New Diagnosis: Check "Use ICD10", type the name or code, and hit Enter. Blue diagnoses can be clicked to narrow down.

Treatment Screen

The central hub for managing the patient's treatment plan. From here the clinician can write clinical notes, order medications, order labs, order diagnostic imaging, and make referrals to specialists.

Immunizations follow a two-step process:

• Step 1 — Check History: Click "Immunization" on the Patient Dashboard to view vaccination history.
• Step 2 — Order: Orders are placed from the "Immunizations" link under the "Plan" section of the progress note.

Patient Lookup (Sherlock)

To look up any patient outside of the appointment schedule:

• Click the magnifying glass / Sherlock icon in the top navigation
• Search by "last name, first name" or by date of birth
• This opens the Patient Hub with access to labs, DI, referrals, Patient Docs, immunizations, and more