Notes. Date Last Revised: 1/1/2016 Date Last Printed: 1/1/2016 1

Transcription

1 Notes Fundamentals... 2 Start a note... 3 Write a note with NoteWriter... 4 Write a note with SmartTools... 6 Pend or sign a note... 9 Dictate part of a progress note Cosign a note with an attestation Edit a signed note Write a handoff report Efficiency Tips Copy a previous note Create a NoteWriter macro to record your common findings Organize, edit, or delete your note macros Jump start routine notes with speed buttons Create a SmartPhrase to reuse text you commonly type Customize your SmartPhrases Pull lab results into your note with SmartLinks

2 Fundamentals There are several methods available for writing notes, and each one has unique advantages. For that reason, many physicians use a combination of methods depending on the length, level of detail, and uniqueness of the note. For example, you can document findings for a physical exam and review of systems by pointing and clicking in NoteWriter, and then complete the rest of the note using SmartTools or free text. Use the methods that work best for you. Method How to Use Benefits NoteWriter SmartTools Free text Partial dictation Voice recognition Click buttons to generate a note. Often used for HPI, ROS, physical exam, progress notes, H&P notes, and procedure notes. Pull in text, patient information, and templates with lists of choices you can select from to tailor your note. Often used to supplement NoteWriter documentation. You type whatever text you want. Use for short notes or to supplement notes written with other tools. Dictate to supplement notes written with other tools. Dictated notes are transcribed into the chart later. You talk and software translates your words into text. Use for long notes or to supplement notes written with other tools. Real-time documentation* Discrete data can be used for reporting Relatively fast, especially when using macros (refer to the Efficiency Tips section for details about macros) Provides a structured template to support thorough documentation Real-time documentation* Discrete data can be used for reporting Faster than free-text typing Provides a structured template to support thorough documentation Real-time documentation* Flexible Fast Real-time documentation* Relatively fast Flexible *Documentation is available as soon as you sign the note. 2

3 Start a note You can write any type of note in the Notes activity. In addition, some navigators include a notes section so you can write a note while working on other related tasks. Start a note in the Notes activity In the Notes activity, select the tab for the type of note you want to write (Progress, Consults, etc.). A. To write a note with SmartTools or free text, click New Note. B. To write a note with NoteWriter, click Create in NoteWriter. Then select a NoteWriter template, such as ADULT DAILY PROGRESS NOTE, and click Accept. NoteWriter opens. When you create a consult note, select the order associated with your consult note and compose your note as usual. When you sign the note, the consult order is marked complete. Start a note in a notes navigator section In notes navigator sections, the tools available vary depending on the type of note: In the H&P Notes and Transfer Notes sections, click Create Note to write a note using NoteWriter. In the Transfer Notes section, click Create Note in NoteWriter to write a note using NoteWriter or Create Note to write a note using SmartTools or free text. In the Discharge Summary section, click Create Note to write a note using SmartTools or free text. Open the Procedure Notes section to open NoteWriter. If you accidentally create a new note in NoteWriter, click close NoteWriter without saving the note. Cancel and then click Discard to Choose to edit your notes in a sidebar, in a floating window, or in the classic note editor by clicking Note Editor Setting in the Notes activity. 3

4 Write a note with NoteWriter NoteWriter helps you write notes quickly by translating the buttons and options that you click into sentences. You can then use SmartTools or type free text to complete your note. 1. In NoteWriter, select the tab for the type of information you want to document, such as ROS. The tabs that appear vary by note type. 2. Document pertinent positives and negatives by clicking buttons. a. Left-click to mark an item positive. b. Right-click to mark an item negative. c. Click again to undo your selection. d. Select the neg check box to mark an entire section negative. 3. Use the system-specific tabs, such as Cardio or Skin, at the top of the Physical Exam tab to document an area in more detail. 4. Review your full note on the Note tab. Add to or edit your note by typing or using SmartTools. Click to remove all documentation on a single tab of the NoteWriter. 4

5 Add comments to your note There are several ways to add comments in NoteWriter: To write a longer comment by typing or using SmartTools, select the Comments tab. To enter comments about a section, such as GU, click. Hover over to see the comment. To add a comment for a positive/negative button, double-click or hover over a button, enter a comment, and press Enter. The button name appears underlined to indicate that a comment exists. Hover over the button to see the comment. Add annotated images to your note Most system-specific tabs on the Physical Exam tab include an image and drawing tools. Annotations you make become part of your completed note. 1. Select a drawing tool on the left to record your observations. To see what each drawing tool is for, hover your mouse over them. 2. Record your observations. a. To add an icon, click once. b. To add an icon of a different size or shape, click and hold the left mouse button, and drag the icon. c. Click to remove the last icon you added. 3. Select the comments tab to include notes, if necessary. 5

6 Write a note with SmartTools SmartTools are charting shortcuts that you can use to pull different information into your documentation: SmartTools SmartPhrases SmartLinks SmartTexts SmartLists Use to pull in Long words, phrases, or paragraphs Information from another part of the chart Templates or longer blocks of text A predefined list of choices You can use SmartTools in many places throughout Epic, such as notes, patient instructions, and letters. If you see these buttons, the field is SmartTool-enabled: Use a SmartPhrase SmartPhrases allow you to type a few characters that automatically expand to a longer phrase or paragraph. For example, typing ".aaa" expands to "abdominal aortic aneurysm." Typing ".hpipneu" and selecting the HPIPNEUMONIAGEN SmartPhrase expands to a long paragraph. 1. In a SmartTool-enabled field, enter a period (.) followed by the SmartPhrase's name (".aaa"). As you type, a list of matching SmartPhrases and SmartLinks appears. 2. Use the arrow keys to select the SmartPhrase you want to use in your note and press Spacebar to insert it. 3. Complete any SmartLists and wildcards (***) in the SmartPhrase. A wildcard (***) is a placeholder. Press F2 to jump to a wildcard and type over it with the text you want to add, or delete it. 6

7 Use a SmartLink SmartLinks help you write notes quickly by pulling, or "linking," information from the patient's chart directly into your documentation. For example, typing ".lastcbc" pulls in the patient's last CBC result. SmartLinks often appear within SmartPhrases, but you can also use them on the fly. Enter a period (.) followed by the SmartLink's name, as you do when using a SmartPhrase. When inserting a SmartLink, press Enter to start a new paragraph after pulling in the SmartLink. Press Spacebar to continue with the same sentence or paragraph. Browse available SmartPhrases and SmartLinks 1. Click on the SmartTools toolbar. The SmartLink/Phrase Butler opens and any SmartPhrases you've created appear. If none appear, select System SmartPhrases to see all available phrases. The Abbrev column shows you what to type after the period (.) to use the phrase or link in a note. The Expansion column shows you the text that the phrase or link pulls in or, for longer phrases, includes a general description of the text. indicates a SmartPhrase. indicates a SmartLink. 2. To find phrases and links, you can: a. Use the Filter tab to select the SmartTools you want to see. b. Search for specific links or phrases. c. Click to mark links and phrases as favorites. d. Use the Sort tab to control which items are listed first. 3. Double-click a SmartPhrase or SmartLink to insert it. To see all available phrases and links, enter ".?" in a note. 7

8 Use a SmartText SmartTexts are standard templates or blocks of text used to write notes for routine visits or patients with problems you see often, such as diabetes. 1. Enter a few letters of the SmartText's name in the Insert SmartText field and press Enter. The SmartText Selection window appears. 2. Double-click a SmartText to insert it. 3. Press F2 to complete any SmartLists and wildcards (***) in the SmartText. Click Show Preview to view the contents of a SmartText before adding it to your documentation. Select from a SmartList SmartLists are lists of common choices that help you quickly customize your documentation. For example, the respiratory history SmartList contains choices like asthma and COPD. SmartLists appear in SmartTexts and SmartPhrases and look something like this: {resp history:19195}. 1. Press F2 to highlight the next SmartList or wildcard (***) in your note. Some values in a SmartList might be selected for you. 2. Click other values to select them. A yellow background indicates that you can select only one value. A blue background indicates that you can select one or more values. 3. If you accidentally select a value, click again to clear it. 4. Right-click inside the SmartList to save your selections and move to the next SmartList or wildcard. Try the mnemonic "left to pick, right to stick" to remember which mouse button to use. Undo a SmartList selection To undo your last selection, click or press Ctrl+Z. To undo any SmartList selection, right-click the SmartList and choose Reselect This SmartList's Selections. Use keyboard shortcuts to complete SmartLists. With a SmartList selected, press Up Arrow and Down Arrow to move through the list. Press Spacebar to select a choice. Press Enter to accept your choices and move to the next SmartList or wildcard (***). 8

9 Pend or sign a note When you're finished writing, press F2 to make sure you completed all SmartLists and wildcards (***) in your note. Then click Sign. If you are interrupted before you're finished writing, click Pend to mark the note as incomplete. You can come back to finish it later on the Incomplete tab of the Notes activity, or access all your pended notes from In Basket: 1. Open In Basket and select the Chart Completion folder. Incomplete documentation like pended notes and orders to cosign appear here. Pended notes have a status of Note Pending. 2. Select a note and do one of the following: a. Click Edit to edit the note without opening the patient's chart. b. If you need to refer to other information in the patient's chart, click Jump To. The chart opens. 3. Make any necessary changes to the note and click Sign. The note disappears from your In Basket. 4. Continue until you've completed and signed all your pended notes. Clinicians should not act on information in pended notes because the notes might contain erroneous or incomplete data. To send a note to other clinicians in an In Basket message, select the note in the Notes activity, click Route, and choose recipients. 9

10 Dictate part of a progress note With partial dictation, you can use other tools to enter part of your progress note text and dictate the rest. For example, if you use NoteWriter to document a patient's physical exam but you want to add a detailed assessment and plan, you can do so using partial dictation. 1. Place your cursor at the point in your note where you want to add a dictation and click. 2. Record your dictation directly in Epic or by using a third-party dictation system. If you are recording directly in Epic, record your dictation and then click Accept. A link appears in your note, which you can click to play back your dictation. If you are recording into a third-party system, a SmartLink appears in your note. When you record your dictation, make sure to mention the dictation number, medical record number (MRN), and contact serial number (CSN) that appear in the SmartLink. 3. When your transcription is processed, you'll recieve a Transcription In Basket message. When you approve the transcription from the message, the text is pulled into your note. Document using voice recognition software The use of voice recognition within Epic requires the installation of third-party voice recognition software, such as Dragon NaturallySpeaking. If you have the voice recognition software set up, you simply need to move your cursor to the location in Epic where you want to document and speak into a microphone or headset. 10

11 Cosign a note with an attestation Add attestation comments when cosigning a resident's note instead of creating a whole new note or taking ownership of the resident's note. When you attest a note as the supervising physician, your comments appear in a separate section above the note text. 1. Go to In Basket and select a Cosign Notes message. 2. Review the resident's note and click Attest. The Attestation window appears. An attestation statement appears automatically. 3. Enter your attestation comment in the bottom pane and click Sign. The note status changes to Attested. You can also add attestations in the Notes activity and notes navigator sections. To copy a previous attestation, click. To edit or remove an attestation you added in error, click Edit Attestation in the Notes activity. Edit a signed note To edit a signed note, you must create an addendum. 1. In the Notes activity, select the note you want to modify and click Addendum. 2. Edit your note and click Sign. 11

12 Write a handoff report Handoff reports allow you to share relevant details with the next clinician caring for a patient. To begin writing a handoff report, select a patient in Patient Lists and click Write Handoff. The Handoff sidebar opens. Edit the information in each section by typing or using SmartTools. Click to erase your comments and start over with the default SmartText, if one exists. Copy the handoff report into your note by clicking. To print a handoff report, go to Patient Lists, select the list of patients you want to print, and click Print > Handoff on the main menu. The printed report is tailored to your specialty and is especially useful during rounds. 12

13 Efficiency Tips Copy a previous note Instead of starting from scratch each time you write a note, you can start from a copy of a similar note. For example, if the patient was seen recently for the same problem, you can copy the note from that visit and then make changes to it as needed. If the note includes SmartLinks, they refresh automatically so your note includes the most recent data. Copying notes can be efficient, but if it's not done carefully, it can lead to unnecessarily long notes with inaccurate or outdated information. When you're reviewing notes, you can hide copied text to de-emphasize content pasted from other sources, like previous notes. You can also hover your mouse over a section to see who originally wrote it. Copy a note in the Notes activity 1. In the Notes activity, select the note you want to copy. 2. Click Copy. A copy of the note opens in NoteWriter or the Copy Note window, depending on which tool was used to create the original note. 3. Update the copied note as necessary to ensure the note is accurate for the current visit. 13

14 Copy a note in NoteWriter In NoteWriter, you can quickly copy all or part of the information in a patient's previous note to use for the note you're writing. For example, if most of the ROS findings from a previous note still apply, you can copy that information forward with a few clicks. Any findings you document before copying the note are preserved, and you can make more changes afterward to make sure the note is up-to-date. 1. Open a new note in NoteWriter. a. To copy an entire note, select any tab and click Copy Note. b. To copy only a specific part of the note, such as ROS or physical exam, select the appropriate tab and click Copy HPI/ROS/Physical Exam (depending on which tab you've chosen). 2. In the Copy window, select a note and review the text in the pane below. 3. Click Accept to add the information to your current note. 4. Update the copied note as necessary to ensure the note is accurate for the current visit. 14

15 Create a NoteWriter macro to record your common findings A NoteWriter macro can help you document a typical exam or procedure more efficiently. A macro is a set of signs, symptoms, and pertinent negatives that you commonly record during an ROS or physical exam, or information that you commonly record in a procedure or progress note. For example, during an ROS, you can document the patient's symptoms and then apply a macro to note all pertinent negatives. Anything you document before applying the macro is preserved, and you can also make changes after applying it. Create a macro on the fly Follow these steps to create a macro on the fly, based on the documentation you've recorded for the current patient. 1. After making your selections in NoteWriter, click to the right of the button and select Create macro from current data. 2. In the Macro Selection window, enter a name for your macro in the Macro field and click Accept. Note any age and sex restrictions that appear. For example, the macro you create might apply only when you're doing a review of systems for females, age 13 and older. These restrictions allow you to create different macros for female, male, and pediatric patients. 3. In the SmartBlock Macro Editor, edit the macro by selecting any other items that you commonly record. 4. To share this macro with a colleague, list her name on the Owners/Users tab in the SmartBlock Macro Editor. 5. Click Accept. Your macro is now available for use. Note that any additional changes you make in the editor are not automatically applied to your note from step To apply this macro in the future, click to the right of the button and select your macro. If you have multiple macros for a tab, select the Set as primary macro check box in the editor to make your most commonly used macro appear at the top of the NoteWriter's macro list. Then click in the NoteWriter to apply your primary macro. 15

16 Create a macro at your convenience Follow these steps to create a macro at any time. 1. In NoteWriter, click to the right of the button and select Create new <name> macro. 2. In the Macro Selection window, enter a name for your macro in the Macro field. 3. In the SmartBlock field, enter the name you noted in step 1. Enter any necessary age and sex restrictions and click Accept. For example, you can make the macro available only when you're doing an ROS for females age 13 and older. These restrictions allow you to create different macros for female, male, and pediatric patients. 4. In the SmartBlock Macro Editor, select the signs and symptoms you commonly review during an exam or the prep steps you frequently perform before a procedure, for example. 5. Select the Active check box. 6. Click Accept. Your macro is now available for use. 7. To apply this macro in the future, go to the tab for the type of macro you created, click the arrow to the right of the button and select the macro. If you have only one macro for this tab, just click to apply it. 16

17 Organize, edit, or delete your note macros In the Macro Manager, you can organize how your macros appear in the NoteWriter so that the ones you use most often are easily accessible. You can also edit, hide, and delete your macros from the Macro Manager. 1. In the NoteWriter, click the down arrow next to and select Launch Macro Manager. The Macro Manager opens. 2. In the Select a SmartBlock field, select the SmartBlock you want to create a macro for, such as Review of Systems by Age. The available macros appear in the Available macros table. The SmartBlock you were working with when you launched the Macro Manager appears in this field automatically. If you want to look up macros for all types of SmartBlocks for the ROS or Physical Exam tabs, clear the Hide SmartBlocks I don't use check box. 3. Make changes to the available macros and click Accept to save your changes. Organize: To rearrange macros so that the most common ones show up at the top of the list, drag the macros to the positions in which you want them to appear. Edit: To modify the selections in a macro, click. The SmartBlock Macro Editor opens so that you can make your changes. Hide: If shared macros created by other users appear in your list, and you don't use them, select the Hide check box for those macros. Hidden macros don't appear when you click in the NoteWriter. Delete: If you own a macro and no longer want to use it, click the next to that macro. Deleted macros appear in the bottom pane. If you want to use a deleted macro again, click to reactivate it. 17

18 Jump start routine notes with speed buttons Add personalized buttons to your notes navigator sections or sidebar so your most commonly used note templates are available in one click. You can create a button that starts a new note using a specific SmartPhrase or SmartText. 1. Click the in the upper-right corner of a notes navigator section or sidebar. The Notes Personalization window opens. 2. Click to add a new button. a. In the Caption field, enter the name that you want to appear on the button. b. Add either a SmartPhrase or SmartText. 3. Click Accept. The button appears at the top of your notes section. You can also use the Notes Personalization window to change the default SmartText that is used in a new note and when attesting to a note. 18

19 Create a SmartPhrase to reuse text you commonly type If you often type the same phrases and sentences while charting, create a SmartPhrase to save time in the future. Create a SmartPhrase from text you type 1. While charting, type the text you want to save as a SmartPhrase. Make sure the text doesn't include any patient-specific information, so you can reuse it for other patients. You can create a SmartPhrase anywhere you see this toolbar: 2. Select the text and click. The SmartPhrase Editor window appears. 3. In the Name field, enter a short, intuitive name for your SmartPhrase. This is the name you'll type to insert the SmartPhrase in a note. You can't include spaces or symbols in the name. Tip: Preface the name with your initials so you can find it easily. 4. Enter a summary of your SmartPhrase in the Short Description field. When you search for your SmartPhrase, this description appears in the results after the SmartPhrase name. 5. If you want to make your SmartPhrase available to other users, designate them on the Owners & Users tab. Owners can update the shared SmartPhrase. Users can only use the SmartPhrase. 6. Click Accept to save and close your new SmartPhrase. 7. To use your SmartPhrase in a note or letter, type a period immediately followed by the SmartPhrase name. Press the Spacebar to insert your SmartPhrase in the note. Create a SmartPhrase from a SmartText If you frequently make the same changes to a certain SmartText, save your edited version of the text as a SmartPhrase. 1. Open a new note. 2. Click to open the SmartPhrase Editor. 3. Click to open a list of SmartTexts. Search for the SmartText you want to edit and click Accept. The SmartText appears in the SmartPhrase window. 4. Edit the text to reflect your preferences. 5. Follow steps 3-6 of the "Create a SmartPhrase from text you type" section of this guide to name and save your new SmartPhrase. 19

20 Customize your SmartPhrases To write notes more efficiently, add SmartLinks and SmartLists to your personal SmartPhrases. You can also add synonyms to make your SmartPhrases easier to find. To edit a SmartPhrase you created, click Personalize on the main toolbar and select My SmartPhrases. The SmartPhrase List activity opens and a list of your personal SmartPhrases appears. Double-click the SmartPhrase you want to edit. The SmartPhrase Editor opens, and you can begin customizing your SmartPhrase. You can delete your duplicate or unused SmartPhrases from the SmartPhrase List activity. Select the SmartPhrase you want to delete and click Remove. Add a SmartLink to pull in patient-specific information Use SmartLinks to pull information from another part of the patient's chart into your SmartPhrase, such as the patient's name or last CBC results. 1. In the location where you want the SmartLink to appear, enter a period followed by the first few letters of the SmartLink's name. A list of matching SmartLinks appears. 2. Double-click a SmartLink to add it to your SmartPhrase. The SmartLink appears in your SmartPhrase symbols, such 3. Click Accept. Click Close. The next time you use this SmartPhrase, patient-specific information appears where you added the SmartLink. 20

21 Add synonyms to quickly find your SmartPhrases Add synonyms to make your SmartPhrases easier to find. When writing a note, you can pull in your SmartPhrase with its name or a synonym. 1. Select the Synonyms tab. 2. In the Synonyms field, enter any other names you might use to search for this SmartPhrase. For example, you might name a SmartPhrase ABDOMINALPAIN and include a synonym of STOMACHPAIN. 3. Click Accept. Click Close. In the future, you can pull in the SmartPhrase by typing a period followed by either the SmartPhrase name or the synonym. Add a SmartList to select from a predefined list of choices Use SmartLists to select from a list of common choices when writing your note. For example, add an abdominal pain SmartList in a SmartPhrase so you can select a different pain level each time you use the SmartPhrase to chart the patient's progress over time. 1. In the Insert SmartList field on the right, enter the first few letters of the SmartList and press Enter. The SmartList window opens, and a list of matching SmartLists appears. 2. Double-click the SmartList you want. 3. Click Add to SmartPhrase to insert the SmartList into your SmartPhrase. The SmartList appears in your SmartPhrase in braces. 4. Click Accept. The next time you use this SmartPhrase, you must make selections from all included SmartLists before you can sign the note. 21

22 Pull lab results into your note with SmartLinks You can use SmartLinks to pull a patient's recent lab results into your notes. By setting different parameters, you can specify which components to include, as well as whether to pull in a certain number of results or to include all the results within a given period of time. Look up component base names To pull in results for a specific component, you need to know the component's abbreviation, or base name. You can find components' base names in lab reports in Chart Review. 1. In Chart Review, select the Labs tab and select a result for the component you're interested in. 2. Click Preview to see the result report in the preview pane. 3. Scroll to the View SmartLink Info section at the bottom of the report and click the lab component link. 4. Note the entry in the Base Name column of the table. This is the base name that you can use with the LASTLAB SmartLink to pull results for this component into your note. Pull in results for specific components To keep your note brief, use the LASTLAB SmartLink to pull in results for specific components. The LASTLAB SmartLink pulls in the name of the component followed by a table listing the date, result value, reference range, and status of the result, as well as any comments entered with the result. In your note, place your cursor where you want to insert the results, enter ".lastlab[basename:#", and press Enter. In place of "BASENAME", enter the base name of the component for which you want to insert results. In place of "#", enter the number of results you want to insert. For example, enter ".lastlab[pocglu:3" to insert the patient's last three POC glucose results. To insert all of a patient's results for the component, enter "*" instead of a number. To insert only the most recent result, omit ":#" and just enter ".lastlab[basename". To insert results for multiple components, separate them with commas. For example, enter ".lastlab[pocglu:3,poccreat" to insert the patient's last 3 POC glucose results and her most recent POC creatinine result. To insert a smaller table that includes only the date and component value, use the LASTLABX SmartLink. Follow the instructions above to set parameters for the LASTLABX SmartLink. 22

23 Pull in all of a patient's recent lab results If you need to insert all of a patient's recent lab results, use the GETLABS SmartLink. You can specify the time period in which to search for results and the display format. If a patient has many recent lab results, using the GETLABS SmartLink can cause your note to become quite long, making it more difficult to read. We recommend using the LASTLAB SmartLink instead to pull in results for specific components. In your note, place your cursor where you want to insert your patient's results. To pull in all of a patient's lab results from the past 6 months, enter ".getlabs[6m,1". Entering "6M" pulls in results from six months back to the date of the current encounter. Replace "M" with "D", "W", or "Y" to specify days, weeks, or years, respectively. The second parameter controls what information appears. Leave this parameter blank to pull in the component name, value, reference range, and status of each result. For example, enter ".getlabs[6m". Enter "1" to pull in all of the above information except for comments. Enter "2" to pull in only the component name and value of each result. 23