PowerNotes. Physician. Created November 2011 by: Clinical Informaticist Team

Transcription

1 PowerNotes Physician Created November 2011 by: Clinical Informaticist Team

2 Table of Contents Opening PowerNotes 1 Finding a PowerNote 1 Encounter Pathway 1 Existing 2 Precompleted 2 Catalog 3 Recent 3 Favorites 3 Icons & Symbols 4 Setting Up Auto Population for PowerNotes 4 Adding a Sentence 6 Moving a Sentence Within an Area 6 Adding an Exclusion Sentence 7 Macros 8 Updating a Macro 9 Deleting a Macro 10 Auto Text 10 Free Text Area 11 Other Text Box 12 Modifying Auto Text 12 Using Auto Text 14 How to Copy & Paste into a PowerNote 14 Smart Templates 14 Copying from the Results Page 15 Insert Images into Your PowerNote 16 Ordering from a PowerNote 17 Diagnosis & Problem List 18 Show & Hide Structure 21 Contributor View 21 Precompleted Note 21 Signing PowerNote 23

3 Opening PowerNotes When you are ready to open a PowerNote there are three different options. 1 st You can click on I&O / Documentation. Then click the Folder 2 nd You can click the +Add on the Inpatient Summary. 3 rd You can click PowerNote/Documentation Finding a PowerNote Open search window. You will see six tabs. Encounter Pathway You can search for a name of a PowerNote You can use the search filter. Starts with Contains Exact Match Once you type the Name in the search window Starts with Contains Exact Match Click the binoculars icon 1

4 Finding a PowerNote Existing Tab This tab allows you to see any PowerNote that has been created on this patient. Current encounter will show only PowerNotes created during this encounter. All encounters will show you all PowerNotes ever created on this patient. Additional options: Copy to a new note. Show all Unsigned notes only. My notes only. You also can Make Correction to an existing PowerNote. You can Delete a note. Precompleted Tab You can search for a PowerNote. Look for only your notes. Any recent notes. Or your Favorites You can also add one to your Favorites You can Delete a PowerNote 2

5 Finding a PowerNote Catalog Tab You will first have to select a catalog in the drop down window like the *2G Admission. You can then select a PowerNote from the window below the search area. Click the (+) sign to explode some categories to see more options. You can also add to your Favorites list from here also. Recent Tab You can select to see either by Encounter pathway or Precompleted notes. You can also add to your Favorites from this window. Favorites Tab You can filter by: Encounter pathways. Shared Precompleted notes only. All Precompleted notes. My Precompleted notes only. You can also Remove from Favorites list from this location. 3

6 Icons & Symbols Setting up Auto Population in PowerNote Setting up Auto Population in PowerNotes Open any PowerNote Look at the top of the page and click on View. Then click on Customize The Customize window will open (See Next Page). 4

7 The Customize window will open Click on the More tab. Then click in the box by Enable autopopulation. Then click OK The next time you open a PowerNote you will get this window. It is recommended to remove all the check marks from areas you will not wish to Auto Populate. The more you leave check marked the slower your PowerNote will open. Once you have selected the areas you wish to have auto populate then click OK 5

8 Adding a Sentence You can add a sentence to a PowerNote paragraph to customize the note to serve your specific needs. To add sentences to your PowerNote first open the Note. Right click on a Heading. Left click on Insert Sentence. This window will open. You will find different additional sentences depending on the PowerNote. They can include but not be limited to: Airway Breast Cardiovascular Chaperone Present Cognition and Specialty Cognition and Speech Dermatology Eye Feet Gastrointestinal Gynecologic Lines and Tubes Musculoskeletal Neck Nursing OB Rehab Teaching Physician Review Left click on the sentence that you wish to include. It will turn red with a check mark next to it. Click OK Moving a Sentence within an Area If I want to move a sentence either up or down on the page you can do so by: First right click within the sentence line area. This pop-up window will open. Click on Move up or Move Down depending on which direction you wish to move it. This will move the line up or down one line space on the PowerNote. You can move any line sentence in any area up or down. You can also move any Section up or down within your note by right clicking on the Section Name. Then click Move Up or Move Down depending on which direction you wish to move it. 6

9 Adding an Exclusion Sentence You can insert into the Physical Examination paragraph an Exclusion sentence. This to use when documenting a patient s refusal or the inability to complete an examination action and the reason why. To add sentences to your PowerNote first open the Note. Right click on Physical Examination Paragraph. Left click on Insert sentence This window will open. You can see the different options in this window. One of the options in this area is Exclusions Left click on Exclusions. It will turn red with a check mark next to it. Click OK The Exclusions sentence is used when documenting a patient s refusal or declining of a physical examination. The Physician can document their deferment for some type of physical examination. Exclusion is now part of the PowerNote. You can now right click in the Exclusion sentence and move it up or down to the location you wish it to appear in the Physical Examination paragraph. (See page 6) 7

10 Macros Macros are partially completed personal templates used as a component for documentation. They can be comprised of terms, sentences, or a paragraph. Macros are used to add to your effectiveness or as a care standard while documenting common activities. Creating a Macro You can create a macro for an entire section such as Objective in the SOAP note. You can create a macro for a section or term such as Eyes. Right clicking on the section title like Objective (example above) or in the section or term like in this example Eye. Once you Right click you will get this pop-up. Click on Save Macro As. Once the Save As window opens you will want to name the macro. It is recommend that you start the name with your initials. Then name it with something that will be clear and understandable for the next time you wish to use it. Then click Create New button. 8

11 Creating a Macro From that point on anytime you open that PowerNote you will see a blue M next to the area that have macros created for that section. To open the macros just click the blue M. You can even create more than one macro for any area. In this example I have a macro for a patient who has normal vision (No Problems), and one that has bilaterally impaired vision and wears glasses (Glasses). Just click the one you wish to use. If you do not have an applicable macro created, you will have to manually fill in the area. You can edit or change any term or sentences even if you used a macro to fill it in to begin with. Updating a Macro To update a macro, select the terms you wish to include or remove within the macro. Right click section name or term next to the blue M then click on Save Macro As When the Save As.. window opens, highlight by clicking on the macro you wish to update. Then click on the Update button at the bottom of the pop-up window. 9

12 Deleting a Macro Right click the section name or term next to the blue M then click on Save Macro As Highlight the name of the macro you wish to delete. Click the Delete button. Then select Yes in the Confirmation window. The macro will be deleted and will no longer be available after you save. Auto Text Auto Text entries allow for free text to be saved and inserted into a note, saving time when entering redundant text or large amounts of text. Auto Text is created, managed and inserted in areas of the note that allow for free-texting. This is the white space found after the note heading. Tip Since Auto Text is available within any section that allows free text box or free text area within the note; the tip is to use logic when creating auto text utilizing a Z in front of your auto text. This will help in eliminating your auto text to not pop up continuously as z is not a common letter used. To clarify, auto text will automatically pop up any time you are typing in a free area therefore putting a z in front of your auto text will limit the multiple pop ups that could occur when typing in free text information. Example: if you create an auto text and name it Patient is to follow up with their primary care doctor in 3 weeks. With auto text every time you type p in a free text area then this auto text will pop up. If you name it zpatient is to follow up with their primary care doctor in 3 weeks. it will only pop up when you type zpatient 10

13 Creating Auto Text Click in the area that allows you to free text. Type or Paste the text you want in this location, then right click. Left click on Save As Auto Text Once you click on Save As Auto Text the Manage Auto Text will Open. Then click on the New Phrase button. Abbreviation line will no longer be dithered. This will allow you to create a Hot key name the text using z naming convention. You will want to place a description of the auto text in the Description line. Click the Add Text icon. A text entry dialog window will open. Enter the free text information that you would like to see as the auto text. Remember you can paste text into the dialog window. (See How to Copy and Paste into PowerChart.) Click OK when complete. Click save at the bottom of the Manage Auto Text window. 11

14 Creating Auto Text in Other If you left click an OTHER you can add free text. Once you click Other the free text area will open, left click on Manage Auto Text Icon. Then follow the instruction on page 11 after this point. Modify Auto Text To modify an auto text do the following: Highlight the Auto text you wish to modify. Right click. Left click Save As Auto Text.. Click the Modify icon. The Formatted Text Entry window will reopen allowing you to edit the Auto text. Click OK Then Save 12

15 Deleting Auto Text To delete an auto text do the following: Highlight the Auto text you wish to modify. Right click. Left click Save As Auto Text.. Click the Delete icon Then Click Save Then Highlight the Abbreviation line. Click this Delete Icon You will see a confirmation window. Click Yes to finish deleting the Auto Text. 13

16 Using Auto Text Click on free text area. Start typing your free text abbreviation and a window will open showing you any options you can select. Double Click the one you wish to use. In this case there is only one. The free text will auto fill at that point. How to Copy and Paste into a PowerNote There will be times that you will want to copy and paste text into PowerNote as a free text, Auto Text or Macro from some other type of computer program. Examples of this would be to create text in Microsoft Word (PC Users) or Keynote (MAC Users). To copy the text, highlight the text that you wish to use then click Ctrl + C on the computer key board. To paste the text into a PowerNote location place the cursor where you want the text to be placed and click Ctrl + V and the text will appear in that location. This works for both PC and MAC users. Smart Templates Some sentences will have Smart Templates (ST) included within them. A smart template will pull information into the sentence in a more organized manor that is set to certain criteria for that smart template. You can set-up Smart Templates to auto populate in a Pre-Completed PowerNote by using the auto populate function see page 4. 14

17 Copying from the Result Page In some sentences you will find areas that you can click that will move you to the results page. You can select all the results by clicking Select All. You can select specific blocks of results by highlighting them by left clicking and then dragging over the data. Then click Include Selected. If you wish to be more specific on your selection you can hold the Ctrl key down and left click on each individual result that you wish to move into your PowerNote. Then click Include Selected This is what you see in PowerNote. 15

18 Insert Images into your PowerNotes To insert an Image from the image file you will need to click within the paragraph that you want the image to be inserted. Then click the Image Icon from the tool bar above the PowerNote. The Drawing Box will launch. Within the Drawing Box, use Open > File to navigate to the image you wish to use. There is both black/white and color images available to pull into your PowerNote. After the desired image is selected the drawing will pull into the drawing box. In the drawing box you can edit it with both text and drawing on it to show insertion points, abnormalities you need noted or to highlight something that needs a visual representation of what has been charted in the PowerNote. 16

19 Ordering From a PowerPlan On some PowerNotes you will find areas to place orders. Left click on the line called PowerOrder and it will take you to the Orders page of PowerChart. Order as you normally would by clicking the +Add button. Complete all required fields and sign. This will then show within the PowerNote everything that you ordered with details. 17

20 Diagnosis and Problem List Left click on Other Diagnosis. The Diagnosis list will open. This page is broken down into two sections. To add a Diagnosis or Problem click the +Add button. The top of the page shows Diagnosis (Problem) being addressed this visit. The bottom section list Problems that have been a past issue noted but may not be during this hospitalization. If you click the Problem Add button you will only have one required field (Yellow) in the problem. 18

21 Diagnosis and Problem List Confirmation Axis I diagnosis Axis II diagnosis Axis III diagnosis Axis IV diagnosis Complaint of Confirmed Differential Possible Probable Provisional Rule out Classification Infectious History Medical Nursing Patient Stated Surgical If you click the Diagnosis Add button you will have four required fields (Yellow). They are: Diagnosis Type Admitting Admitting Diagnosis Billing Diagnosis Discharge Final Other Post-Op Diagnosis Pre-Op Diagnosis Principal Reason For Visit Referring Suggested billing Working Type in the Problem or Diagnosis within the search window the name you are looking for. Then click the Binoculars. The first time the Diagnosis Search window opens you will want to change Terminology search to only ICD-9 codes. To do this click the ellipsis button to the right of terminology. You will see a check mark next to All terminologies change that to ICD-9-CM. Then click OK. 19

22 Diagnosis and Problem List This will show you a list of Diagnosis or Problem below. You can change the search filter from: Starts with, Exact match, Contains. You can also search by code number. Highlight the Diagnosis or Problem Click OK That takes you back to the Diagnosis or Problem window. You then need to answer: Type Confirmation Classification You have four buttons to choose from: Ok (Just adds it to the Dx list.) Ok & Add New (Adds it to the patient list plus takes you back to the search list so you can search for and add additional Problems or Diagnosis.) Add Problem & Diagnosis (Adds it to both the Problem list and the Diagnosis list at the same time.) Cancel (closes the window without doing any of the above) You can right click on the Diagnosis and add it to your Favorites list. You will need to create a folder if you have not already done so. Then click OK. Then click Include 20

23 Show/Hide Structure While documenting in PowerNotes, paragraphs are able to be expanded or collapsed. This is accomplished by using the <Show Structure> and <Hide Structure> terms. <Show Structure> displays the structures of a paragraph including the sentences and terms. <Hide Structure> collapses the paragraph hiding the sentences and terms. If terms have been documented within the paragraph, the textual rendition of the paragraph will display. Contributor View The Icon is Located in the right hand corner of the note screen. This allows you to see what the completed note is going to look like before signing it. Precompleted Note PowerNote allows for the creation of Precompleted Notes which can streamline the documentation process for common conditions. Precompleted notes allow for the ability to customize a template by adding additional sentences or other templates using the standard templates supplied. Precompleted notes are especially helpful when patients present with common problems or conditions (Example: Hypertension or Coronary Artery Disease.) Precompleted Note can be used to streamline the actual visit documentation for common findings. Tools such as macro s and auto text can be used to streamline documentation based on the exam and findings rather than pre-documenting them. 21

24 Creating a Precompleted Note Open a patient chart. Then open and select the PowerNote you wish to use. In this case we are going to use Progress Note Acute Care Document the typical encounter; select the recurring data elements and excluding patient/encounter specific data. It is not recommended to document Orders or Diagnosis within a precompleted note. Those should be saved in Macros Once the note has been documented, from the Documentation menu, select Save As Precompleted Note. This will open the Save As Precompleted Note dialog box. In the Note Title area enter a title for the Precompleted Note. Select Save as New to save the note. The Precompleted Note is now a user specific that can only be used and updated by the creator of the note. 22

25 Searching for a Precompleted Note From the Open Note dialog box, select the Precompleted tab. Enter the name or part of the name of the precompleted note and select Search (The Binoculars). There are several filters available when searching. To select a specific filter or filter(s) use the check box next to the filter name. Listed below are the results for the following combinations: My Notes only: Search personal precompleted notes. My Notes only and Favorites: Search personal precompleted notes that have been added to my favorites. My Notes only, Favorites and Recent: Search recent precompleted notes that have been marked as favorites. Signing PowerNote Once you have completed the PowerNote and you are ready to sign, find the sign icon on the icon row above the PowerNote. The first time the Sign Note window opens you will want to change the Type to Progress Note. To do this first right click in the window and pick All Note Type List. If you do not change the type it will be in a wrong folder. This will make it extremely difficult for others to find it in the chart later. You can change the name of the note to reflect what the note is about. Once you have the note titled as you want then click the OK at the bottom of the popup window. 23