Documenting an Operation Note Using the Surgical Op Note (PowerNote)

Transcription

1 Documenting an Operation Note Using the Surgical Op Note (PowerNote) The Surgeon Op Note PowerNote is the document template to use to document Operation Notes. PowerNotes contain a range of features including: Ability to add Procedures and content from the Chart such as Orders Draw on and insert diagrams and pictures Customise Op Note Settings to save time Table of Contents Open a Surgical Op Note Page 2 Navigating the Surgical Op Note Page 3 Documenting in the Surgical Op Note Page 4 Adding the Procedure Performed Page 5 Streamlining your Search for Procedures Page 6 Editing how a Procedure is Displayed Page 7 Saving Favourite Procedures Page 8 Accessing your Saved Favourite Procedures Page 9 Adding Images within the Op Note Page 10 Placing Orders within the Op Note Page 11 Finalising the Op Note Page 12 Customising Op Note Settings Changing Font Size and Style Creating Pre-Completed Notes Creating Case Attendees with Macros Page Page 1 of 17

2 Open a Surgical Op Note Open the patient s chart/medical record and click on Documentation in the Patient Menu NOTE: DO NOT click the Add button next to Documentation this will not open the standard Progress Note templates. In the Documentation screen click the drop-down arrow next to Add and select PowerNote 1. Open and use a Note by clicking on one of three tabs and double-clicking on a Template: Blank Surgical OP Note - Click the Catalog tab and click the Catalog dropdown menu and select Surgery Precompleted Tab Favourite Tab The Surgical OP Note will open for editing. Page 2 of 17

3 Navigating the Surgical Op Note On the left of screen is the Table of Contents On the right of screen is the Note Body Table of Contents Note Body The PowerNote will automatically include the surgical Case Number if you are in the correct inpatient encounter. Mandatory fields show in the Table of Contents with a red Asterisk. The Procedure Performed is the only Mandatory field in the Note. Navigate via the Table of Contents by clicking the + next to each heading, then click on a subheading/section to jump to it in the Note Body. Most of the sections in the Surgical OP Note allow free-text typing of information. Page 3 of 17

4 Documenting in the Surgical Op Note Use the structure and document against a section by clicking on this symbol = = = For the Discharge Plan & Post-op Follow up, click on a frequently used Response to select and include it in your final Note or add further instructions by clicking the section === Free-text parts of your note by clicking on a heading or section and clicking Use Free Text Preview the finalised Note by clicking the very small Display Contributor View button on the right of screen directly above the Scrollbar. Click it again to continue editing the Note. Page 4 of 17

5 Adding the Procedure Performed The Procedure Performed section is a Mandatory Field. 1. Click Add to Procedure History in the Note Body 2. Click Add 3. Add a procedure by typing in the Procedure within the search field and clicking the Binoculars to search for it. Remember to add the procedure as a Favourite if you use it frequently, this saves time searching. Page 5 of 17

6 Streamlining your Search for Procedures. Modify the Procedure Search filters to get a more comprehensive Procedure search. Change it to a Contains Search and click the ellipsis field and select Procedure. next to the Terminology Axis You will only need to do this once on your personal login and it will default to these settings. NOTE: If you cannot find the exact terminology for a Procedure, click on a Procedure that most closely matches it and click on View Synonym to see closely related procedures. Page 6 of 17

7 Editing how a Procedure is Displayed In the Add Procedure window you can add more details to a Procedure, or change how it displays in the Surgical Op Note and in other areas of iemr. 1. Use the Comments field to add any details to a Procedure 2. Use the Display As field to have the Procedure display differently in the patient s chart from the SNOMED-CT nomenclature selected. Note the procedure will still be coded as the procedure selected. SNOMED CT nomenclature 3. Once any details have been edited click OK to add the Procedure or click OK & Add New if you need to add multiple procedures for the patient. 4. To include the Procedure in your Surgical Op Note select it from the Procedure History window and click Include To add multiple Procedures to the Note hold the Ctrl key to select each Procedure Page 7 of 17

8 Saving Favourite Procedures Save time typing and searching for commonly performed Procedures by using Favourite Procedures. 1. Type in the Procedure into the search field within a note The Procedure Search window will open. 1. Single-click on the relevant Procedure and click Add to Favourites 2. Select or create and name a Favourites folder and click OK 3. Add more Favourite Procedures by typing in and searching for another procedure in the search bar of the Procedure Search window If you are just saving Favourite Procedures click Cancel when finished so that you do not add these Procedures to the patient s chart! Page 8 of 17

9 Accessing your Favourite Procedures 1. Click on the Favourites folder at the bottom of the Add Procedure Window 2. Double-click on a Procedure to add it to the case 3. Add any additional details and click OK Page 9 of 17

10 Adding Images within the Op Note The Surgical Op Note PowerNote can have images added to it. 1. Click on the subheading/section you want to image to appear under 2. Click the Insert Image button in the Editing Toolbar at the top of the Note The Drawing Box window will open. 3. Either free-draw into the box or follow below to use a pre-loaded image 4. Click the Open button 5. To preview the available images click the Change Your View button 6. Select an image and click Open 7. In the Drawing Box you can Trim and zoom-in on an image using the Editing Toolbar 8. Draw on and edit the image as required then click OK the image will appear against the section you selected Page 10 of 17

11 Placing Orders within the Op Note You can place Orders from the PowerNote 1. Click on either of these two sections to use this feature: Specimens Sent to Pathology? Yes Post Operative Orders Additional Orders 2. The Add Orders window will open 3. Click Add to place any new Orders if required 4. To include any Orders into the Note, multi-select any relevant Orders and click Include Selected The selected Orders will now be documented into the Note. Page 11 of 17

12 Finalising the Surgical Op Note 1. Once the Op Note is completed click Sign/Submit The PowerNote will now appear in all documentation areas of iemr; Continuous Doc, Documentation and Clinical Notes View. You can preview the finalised Note by clicking the very small Display Contributor View button on the right of screen directly above the Scrollbar. Click it again to continue editing the Note. Page 12 of 17

13 Customising PowerNote Settings To save time documenting the Surgical Op Note PowerNote, you can create Precompleted Notes as well as Favourite Procedures. Macros can also be created to save time entering in Case Attendees, and you can also change the Font Style and Size of the Note. Changing Font Style and Size You will only need to change the Font Style and Size once, this preference will save to your iemr profile. 1. Open a new Surgical Op Note 2. Click on View in the PowerChart Menu at the top and select Customise The Customise window will open. 3. Select the Font tab and edit the Font settings then click OK when finished The following Font Styles and Size are recommended: Style: Tahoma & Déjà vu Sans Mono. Size: 12 Page 13 of 17

14 Creating and Updating Pre-Completed Notes Pre-completed Notes can be created to save time documenting an Op Note. These Pre-completed Notes can also be shared to other iemr users in the same Hospital. You can edit and update Pre-completed Notes at any time. NOTE: Images and coded Procedures, Problems and Orders cannot be saved into a Pre-completed Note. 1. Open and create a new Operation Note 2. Type up the Note in a format/template as desired 3. To save as a Pre-completed note click on Documentation in the PowerChart Menu and select Save as Precompleted Note 4. Title the Note and then click Save as New or Update Existing Page 14 of 17

15 5. To use a Pre-completed Note when starting a new Op Note click on the Precompleted Tab or if added to it the Favourites tab Add a Pre-completed Note to the Favourites tab by selecting the Note in the Pre-completed tab and clicking Add to Favourites. Updating Existing Pre-Completed Notes 1. Open the Pre-completed Note you want to update 2. Edit the note as desired then update the Note by clicking Documentation in the PowerChart Menu and selecting Save as Precompleted Note 3. Click Update Existing Page 15 of 17

16 Creating and Using Macros to Enter Case Attendees Macros allow users to enter in saved phrases or sentences against sections in the PowerNote. This feature is useful for quickly entering in Case Attendees into the Op Note. 1. Open an Op Note and click on one of the Case Attendee roles e.g. Surgeon(s) 2. Search for and select the desired person then click OK 3. When added you can right-click and Add Comment to add any additional information against that Case Attendee 4. To save the person as a Macro right-click on them and select Save Macro As 5. Title the Macro as the name of the person then click Create New or Update A blue M will display next to any section with Macros saved to it. Page 16 of 17

17 Using Macros To use a Macro to document against a section: 1. Click on the blue M and select the Person or Phrase you want to use Macros can also be used to add commonly used sentences or phrases against any Section. Page 17 of 17