PowerNote Power Tip Compendium

Transcription

1 PowerNote Power Tip Compendium Creating Macro s.. p 1 Creating An Auto Text.. p 2 Setting Up Auto Population.. p 3 Setting Up a Personal Note Type List.. p 4 Saving a Precompleted PowerNote p 5 Signing PowerNote to the Correct Type. p 6 Consolidated Problems on the Inpatient Summary v4.. p 7 Each training page has a QR code printed on them that can be scanned with your smart phone or IPad. Each one will take you to a short video training on the subject matter that Power Tip sheet covers. If you received this compendium electronically you can click on the QR code and it will take you to the video training.

2 Creating Section Macro s Creating Macro s Macro s allow you to create an auto population within a sentence or section to reduce the number of clicks it takes to complete a PowerNote. You can create as many Macro s as you need or want. 1. I have selected No in most of the sections. In this example Recent visual problem has a strike through (Do this by double clicking it) when the PowerNote is complete it will show No Recent visual problem. 2. Go to the Section title and right click on it. In this example Review of Systems. Then move down and click on Save Macro As. 3. The Save As window will open so you can name the Macro. This will help you to easily identify it for using it later on other patients. 4. Then click Create New button at the bottom of the pop up window. The next time you open the PowerNote 1. To use your Macro look for the M next to the Section name. 2. Left click on the M and a pop up box will open listing all the Macro s you have created for this section. In this example there is only one. 3. Left click on the Macro you wish to use. It will fill in the section. You can still edit any of the Macro s entries so it will be appropriate for the new patient. You use the same process for an individual sentence except you right click on the sentence title. If you have a smart phone or IPad with an QR code

3 Creating An Auto Text Auto Text allows you to create text that you would routinely use in the free text areas in a PowerNote. 1. Start by clicking on Use Free Text. 2. Then add the text you wish to add to the free text area. You can create the text here or you can create it in a Word document and cut and paste it into this area. Also with some preplanning you can add Underscore ( _ ) in locations where information may be different from one patient to another. This could be names or dates. 3. Next Highlight the text with your mouse. 4. Right click on it and then left click on Save As Auto Text. 5. The Manage Auto Text window will open. 6. You will need to enter an Abbreviation for the auto text (it is recommended that you begin it with a z so it will not give you a pop up for other things you might type). 7. Then type in a description of the auto text. 8. Then click the Save button. Using auto text the next time you open a PowerNote: 1. To use your Auto Text, left click on the Use Free Text then start typing the abbreviation you used. A Pop up will open with the complete abbreviation. Then click on it and the text will fill in. 2. IF you have preplanned the auto text with the underscore ( _ ) all you do is click the F3 key and it will go to the first one. Type in the information needed in that space. Click F3 key again and it will go to the next underscore. 3. You can still edit the text in any other additional ways you would need for your patient. If you have a smart phone or IPad with an "QR code

4 Setting up Auto Population to Smart Templates 1. Open any PowerNote. 2. Go to the top of the page to View. Then click on Customize 3. The customize window will open. Then click on the More tab in this window. Then click inside the box next to Enable autopopulation. 4. Then click OK. 5. Close the PowerNote you just opened. 6. Then reopen a PowerNote and you will see this window. 7. The more check marks you have, the slower the note will open. 8. If you are looking for the Smart Templates look for the ones with a single line. 9. This window will open every time you open a PowerNote so that you can add or subtract items. If you have a smart phone or IPad with an QR code

5 Setting Up a Personal Note Type List This tip will help you set up a short list of PowerNote types when you sign your PowerNotes. 1. Open a PowerNote 2. Go to the top of the Page and click on View and then on Customize 4. When the Customize window opens go to the Document Type tab. 5. In Default Note Type click the drop down arrow and change it to Progress Notes. 6. In Default List Type change Personal Note Type List. 7. Highlight the note type in the left column and then click the single arrow button and move it to the right column. (You can select and move other note types you want on your personal list by repeating the process above.) 4. Click the Apply button and then click Ok. 7. When you are ready to Sign the PowerNote, right click the *Type and then left click on Personal Note Type List. 8. Then when you click the *Type drop down arrow you will only see the type of note you have moved into your list. If you have a smart phone or IPad with an QR code

6 Saving A Precompleted PowerNote 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.) 1. Complete the PowerNote you wish to use. Document the typical encounter information; select the recurring data elements. Do not include patient/encounter specific data. It is not recommended to document Orders or Diagnosis within a precompleted note. 2. Go to the top of the page to Documentation. 3. Save as Precompleted Note 4. The Save As Precompleted Note window will open. Title the note as you wish to appear. The Encounter pathway is gray meaning you cannot change it. It shows what type of PowerNote you are saving. In this example Progress Note, Acute Care. 5. Then click the Save as New button. 6. The next time you need this note you will find it under the Precompleted tab. 7. If you place a check mark in My note only this will filter out other notes and you will only see your notes. 8. Double click the title and the PowerNote will open. 9. You can edit the PowerNote as needed to make it patient specific. If you have a smart phone or IPad with QR code scanner scan the this code for a short video tutorial.

7 Signing a PowerNote to the Correct Type The first time you sign a PowerNote you will see that it is trying to save it as a ED Physician Note. It will give very limited options in the drop down window. This Power Tip will show you how to fix this issue so the Note will save under the correct PowerNote type as well as adding an Endorser if needed. 1. Right click in the window that has ED Physician Note. 2. Then left click on All Note Type List. 3. Then click on the drop down arrow and scroll down to the type of note you are signing. In this example it is a Progress Note. 4. It will remember this setting from now on for you. If you have a smart phone or IPad with an QR code Requesting Signature or Review from an other Provider You can send your PowerNote to another provider s message center for counter signature or to review by doing the following: 1. Click in the box next to Request endorsement. 2. The endorsement line will turn yellow. 3. Type in the Provider name in the Endorser line. Enter last name, first name. (You can search if you need to by clicking the binoculars.) 4. Click the drop down in Type and select Sign or Review. 5. The other two fields are optional. 6. Then click the Sign button at the bottom of this window.

8 Consolidated Problems On the Inpatient Summary v4 page you can manage your diagnosis and problems for your patient quick and easy. Definitions: Diagnosis displays problems being treated with the current hospital stay. Problems displays chronic medical conditions. Examples would be: CHF, Diabetic, ALS. Adding Diagnosis In the search window just below Add new as: Diagnosis you can start typing in the current problem (Diagnosis) you wish to add. If you want the diagnosis for your patient to show in both the diagnosis and problem list, you will need to change the setting on the add new as before you start searching for a medical issue. Left click on Diagnosis. Pick the area or areas that you wish to add the patient medical issue into. Note: When you refresh or close the patient chart the Add new as: will default to Diagnosis. Search Suggestions: The more information you provide, the more defined the search will be. A list will appear as you type, similar to a Google search. o Example would be a Skin Carcinoma of the Scalp. You could search under: Skin Carcinoma or Carcinoma, Skin Click on the line and it will be added to the Diagnosis area. Adding Diagnosis from the Problems list. If your patient has an on going chronic medical problem listed in their problem list, You can add it very easily to their Diagnosis list by clicking on it (this highlights it in blue) and dragging it up to the Diagnosis list. The (*) will show next to the new diagnosis until your refresh you computer by clicking the Refresh button. Doing it in reverse order. You can also drag a Diagnosis to the Problems list just as you did in the process above. Historical Section. Historical section will show you past Diagnosis & Problems that have been resolved. You can also drag these to the Diagnosis and/or Problems list areas. If you have a smart phone or IPad with QR code scanner scan the this code for a short video tutorial. Please CPOEquestion@CoxHealth.com