User Guide — Hospital Transcription
athenaOne for Hospitals & Health Systems
With the transcription feature, transcriptionists can add transcriptions to a patient's hospital chart, and add an addendum before and after physician sign-off.
Physicians can review and sign transcription notes in the Clinical Inbox and the patient chart. Physicians can also add an addendum to a signed transcription note.
To enter transcriptions, you must have the Inpatient Transcriptionist role.
To view and sign transcription notes in the Clinical Inbox, you must have the Inpatient Physician role.
To edit a transcription, you must have a physician role.
To add an addendum to a transcription, you must have the Transcriptionist role or the Inpatient Clinicals: Transcribe permission.
- In the patient chart, click Add Transcription in the green workflow menu.
- Note type — Select the note type.
- Time and date of dictation — Enter the date and time the information was dictated.
Tip: You can enter "now" in the time field to input the current time and date, or you can enter "t" in the date field for the current date. - Dictated by — Search for and select the provider who dictated the note.
- Transcription — Enter the text of the transcription.
Tip: To save a note to reuse later, click the star icon . Enter a Shortcut name and click Save.
- Click Enter Transcription.
The patient briefing appears. The note appears listed in the briefing, under Recent Notes, and in the Notes tab of the hospital chart.
Note: If you leave the workflow before you click Enter Transcription, transcription, athenaOne saves the information you entered automatically. All clinicians with access to the patient's briefing can view the content with "transcription in progress" status.
- Display the patient's briefing: Click the athenaOne logo in a department that uses athenaOne for Hospitals & Health Systems to display the Patient List, and then click the patient's name in the Patient List. The patient briefing is the "front page" of the chart.
- In the Recent Notes section, click the transcription in progress.
The transcription window appears.
- Note type — Select the note type.
- Time and date of dictation — Enter the date and time the information was dictated.
Tip: You can enter "now" in the time field to input the current time and date, or you can enter "t" in the date field for the current date. - Dictated by — Search for and select the provider who dictated the note.
- Transcription — Enter the text of the transcription.
Tip: To save a note to reuse later, click the star icon . Enter a Shortcut name and click Save.
- Click Enter Transcription.
- In the patient briefing under Recent Notes, or in the Notes tab in the patient chart, click the note to open it.
- Click ADDENDUM.
The Addendum text box appears. - Enter the addendum and click Sign Addendum.
Note: If you add an addendum after the physician signs off on the transcription, the physician must also sign your addendum.
- Display the patient's briefing: Click the athenaOne logo in a department that uses athenaOne for Hospitals & Health Systems to display the Patient List, and then click the patient's name in the Patient List. The patient briefing is the "front page" of the chart.
- In the Recent Notes section, click the entered transcription to edit.
Note: You can also access the transcription on the Notes tab in the patient chart.
Edit these fields as needed
- Note type — Select the note type.
- Time and date of dictation — Enter the date and time the information was dictated.
Tip: You can enter "now" in the time field to input the current time and date, or you can enter "t" in the date field for the current date. - Dictated by — Search for and select the provider who dictated the note.
- Transcription — Enter the text of the transcription.
Tip: To save a note to reuse later, click the star icon . Enter a Shortcut name and click Save.
- Click Sign Transcription.
The updated transcription appears in the Recent Notes section and on the Notes tab , labeled as "Closed by [physician's name]."
Note: You can click the transcription to add an addendum after signing the note.
- Click the Notes row in your Clinical Inbox.
- Click a transcribed note to view it in the center pane.
- Review the note.
- Click Sign (in the upper right corner of the note).
The next note in the Clinical Inbox list automatically appears in the center pane.
Note: You can click Next to display the next note without signing.
Transcriptionists must re-enter information for all unsigned transcribed hospital courses entered before Release 17.3, and the physician must sign the note again.
If the transcriptionist is not available to re-enter the information, the physician can create a new hospital course and re-enter the information. The unsigned note started by the transcriptionist will close once the patient stay closes.
Physicians and transcriptionists must add the dictation date and time when entering and signing a transcribed hospital course.
If a patient has both a transcribed hospital course and a non-transcribed hospital course, they appear together in one text box in the hospital course note. The physician-written hospital course is placed before the transcribed hospital course.