NoteSwift for Aprima

Transcription

1 NoteSwift for Aprima Tips and T ricks to get the Most out of Your EHR NoteSwift 4989 Peachtree Parkway Peachtree Corners, GA /30/2013

2 1 NoteSwift for Aprima

3 NoteSwift for Aprima 2 Contents First Things First... 3 Assumptions... 3 About This Document: Typographic Weirdness and Helpful Info... 4 Download and Installation... 7 Downloading... 7 Installation... 9 NoteSwift Forms Aprima Interface Chief Complaint History of Present Illness Other Commands Available in the HPI Form Review of Symptoms Past Medical History Social History Medication History Family History Allergies Physical Exam Diagnosis Prescribe Plan... 25

4 3 NoteSwift for Aprima Introduction First Things First Please check the following before starting. 1. Do you have Dragon Medical Practice Edition (DMPE) installed? 2. Do you have Aprima installed? 3. Do you have NoteSwift installed? The section entitled Download and Installation gives instructions on installing NoteSwift for Aprima. If you can answer yes to all three, then continue! If you need to install any of the programs listed above, do so before proceeding. Assumptions This document assumes that you are comfortable using speech recognition and that you are able to work with your EHR capably with or without speech recognition. If you are not comfortable with either, seek training before using NoteSwift.

5 NoteSwift for Aprima 4 About This Document: Typographic Weirdness and Helpful Info There are certain typographic conventions in this document which, once you learn them will help you discern what is typed, clicked, or said in each example and exercise. NoteSwift commands, words you say to NoteSwift when you want something to happen, are in bold and initial capitals such as History of Present Illness. Where you need to pause your voice for a moment in between commands, we put a comma in the instruction. For example, Exam, neuro, numbness on the right foot. You would pause briefly where the commas appear. If the NoteSwift form has a Next button, it allows more than one listed item. Say or click Next to add each item into your form. When finished, say or click Done to enter all information into the form.

6 5 NoteSwift for Aprima If you are using a PowerMic hand held microphone, you have the ability to define hotkeys that can enter text and navigate you around the screen. The PowerMic II uses the defaults below. You can find more information on how to set your hotkeys in your PowerMic II and DMPE documentation. This is the predefined hotkey to enter text for the PowerMic II NOTE: In this manual we assume you will dictate Next and Done, or that you will use a predefined hotkey on a microphone or your keyboard to accomplish the Next and Done functions. When we say press the Next hotkey in an instruction, this means whatever hotkey you have defined to work best for you.

7 NoteSwift for Aprima 6 The Good Doctor icon. Whenever you see this icon, it means we have some important and helpful information for you from the Good Doctor and founder of NoteSwift, Dr. Chris Russell. These tips and tricks will help you learn best practices when working with NoteSwift and your EHR. Here is your first tip from the Good Doctor! Often, it can be quickest to use the hotkey assigned to the Next button to get through the forms and templates. The Next hotkey can be assigned through the NoteSwift Options menu, or through the PowerMic options (see image on previous page) found in Dragon Medical Practice Edition (herein after referred to as DMPE).

8 7 NoteSwift for Aprima Download and Installation Downloading Important: Be sure that you have DMPE already actively running on your system and Aprima ready to be run when needed before you start the download process. In order to downloading NoteSwift on your computer please take the following steps: 1) Turn off UAC (User Account Control) settings based on your Operating System. Windows 7 instructions for turning off UAC settings Click Windows Start button -> Control Panel -> User Accounts -> Change User Accounts Settings. Slide the slider down to the bottom to Never Notify. Windows 8 instructions for turning off UAC settings Charm pop out window -> Control Panel -> User Accounts - > Change User Accounts Control Settings. Slide the slider down to the bottom. 2) Install NoteSwift for Aprima on your computer by entering into your internet browser and hitting the enter key. The NoteSwift for Aprima download page will load into your browser. 3) Choose the Install button from the NoteSwift for Aprima download web page (see image below). 4) Choose the Run button from the pop up window at the bottom of the download page.

9 NoteSwift for Aprima 8 5) Accept the Microsoft Supplemental License Terms by clicking on the Accept button in the dialog that appears just before the download begins. This dialog may or may not appear depending on your system settings. 6) Multiple dialogs will appear during the installation process. Finally, you will see the NoteSwift Open User dialog appear. This indicates the download process was successful.

10 9 NoteSwift for Aprima Installation Installation starts immediately after the download has completed. During installation of NoteSwift you will be asked to create a user. You need to create a username and select the name and version of the EHR you are using. Once you have made your selection choose the Done button from the New User dialog. During install, NoteSwift collects data from Aprima to better understand the way you work. This process can take several minutes (explained in the image below). Do not touch your mouse or keyboard during this process as this will interrupt the data collection and abort install.

11 NoteSwift for Aprima 10 The installation process will ask you to perform the following steps. 1) Start Aprima. If you already have Aprima open, close it and then start it again. 2) In Aprima, start a new empty patient note and click the CC tab. 3) The setup will ask you to click the OK button on the setup dialog. 4) Click inside the Note text box toward the top of the newly created note in Aprima. This will start the data collection process. Once the setup process starts collecting data (after clicking the Notes edit box) it is important NOT to touch your mouse or keyboard until the process is finished. The setup process is finished when you see the User configuration complete message. You are now ready to use NoteSwift!

12 11 NoteSwift for Aprima NoteSwift Forms NoteSwift forms allow you to dictate free text narrative, or, structured data where NoteSwift does the searching for you from a defined list. In this document we go through each NoteSwift form and show you how to create the patient note quickly and easily whether you need free text or structured data. NoteSwift Forms are: Chief Complaint History of Present Illness Review Of Systems Past Medical History Social History Family History Allergies Current Medications Physical Exam Diagnoses Prescribe Plan* Services Ordered Services Provided * The Plan tab is reached by speaking one of the following commands: Internal Notes Visit Notes Patient Instructions Exercise Return Visit

13 NoteSwift for Aprima 12 Aprima Interface The default setting for Aprima is to have all of the panes expanded. This is the way NoteSwift expects Aprima to be so that it can interact with the EHR. If you are experiencing any problems with recognition you may want to check that all your panes in Aprima are expanded and not closed. In order for NoteSwift to interact properly with the Aprima you should always have DMPE, Aprima, and NoteSwift open at all times.

14 13 NoteSwift for Aprima Chief Complaint Call up the Chief Complaint form. Chief Complaint The NoteSwift Chief Complaint form appears. Dictate the patients complaint. For example: Dizziness The word dizziness will appear in the Chief Complaint form. Dictate a Note for the Chief Complaint form such as: For 6 Weeks The Note form is updated with this information. If finished, click or say Done. If you would like to dictate additional information, say Next and dictate another complaint following the steps as noted above.

15 NoteSwift for Aprima 14 History of Present Illness Call up the History of Present Illness form. HPI The History of Present Illness form appears. Dictate the patients history. For example: He comes in today due to dizziness. Six weeks ago he awoke with severe spinning vertigo and left ear tinnitus. The words you dictated will appear in the HPI form. If there was existing highlighted text already in the form, new dictation will replace it. Use your hotkey to click the Done button or, say: Done Other Commands Available in the HPI Form Append moves the cursor to the end of the existing text and adds additional dictation to the end of the previous dictated notes. Recover brings back the text from your prior HPI dictation. This is useful if the text was left from a previous dictation.

16 15 NoteSwift for Aprima Review of Symptoms Call up the ROS form: ROS Dictate the symptoms into the ROS form. NoteSwift defaults to positive findings, if you would like to dictate a negative, simply say negative before the symptom. In the example below the patient is positive for dizziness and tinnitus. Say: Dizziness Press the Next button or say Next Tinnitus In left ear Once your review of symptoms is complete, say Done Or click the Done button

17 NoteSwift for Aprima 16 Past Medical History Bring up the Past Medical History form. Say Past Medical The Past Medical History form appears. Enter the medical history of the patient. Say: Hypertension A list appears. If more than one choice appears choose the item in the list you wish to select and then click Next if you wish to dictate more history, or Done, if you are finished dictating the history.

18 17 NoteSwift for Aprima Social History Call up the Social History form, say: Social History The Social History form appears. Dictate social history information such as: Tobacco History Current Every Day Smoker (This text will appear in the Item field) (This text will appear in the Detail field) 20 Pack Year History (This text will appear in the Note field) Press the Next hotkey. The text appears in the Aprima window and you can continue dictating social history information. Once done with your dictation Click or Say Done. The Good Doctor Says: Don t smoke as it is bad for your health!

19 NoteSwift for Aprima 18 Medication History Call up the Medication History, Say: Med History Dictate the medications your patient is taking. Try these examples to see how to dictate medications in this form. (*Say mg as milligrams.) Say or click the Next button after each medication. Lisinopril 20 mg daily Aspirin 81 mg daily Norvasc 5 mg daily NoteSwift does the lookup for you and puts the dose in the right places. This can be very helpful if a patient takes several medications. Click or say Done when you finished entering Medication History information.

20 19 NoteSwift for Aprima Family History Call up the Family History form: Family History Dictate into the family history form, pausing where you see commas, and remembering to say or click Next after you have finished dictating each individual s history. Mother, Hypertension, Alive Father, Diabetes Mellitus, Deceased Click or say Done when you are finished with the family history.

21 NoteSwift for Aprima 20 Allergies Call up the Allergies form, Say: Allergies Then speak the name of the allergen, for example, Eggs. NoteSwift will search for the allergen in Aprima and the cursor will jump to the Reaction box. Dictate a reaction and then press the Next hotkey to enter the allergen into Aprima. Click or say Done when you are finished entering the allergen.

22 21 NoteSwift for Aprima Physical Exam Call up the Physical Exam form: Exam Dictate into the Physical Exam NoteSwift form. Remember to pause your voice at each comma you see in the example below: Extra ocular movements intact Left nystagmus on left gaze

23 Click or say Done to enter the Physical Exam information. NoteSwift for Aprima 22

24 23 NoteSwift for Aprima Diagnosis To add a diagnosis to the patient s chart, call up the Diagnosis form: Diagnosis Say your diagnosis, in this example: Pneumonia. NoteSwift will search for the diagnosis. You can then dictate an assessment narrative associated with that diagnosis. Press the Next hotkey to enter the diagnosis into the chart. If the Diagnosis search returns more than one item, NoteSwift will use the first item on the list unless you click on another item on the list, in which case it will use that item. Click or say Done when you are finished with Diagnosis.

25 NoteSwift for Aprima 24 Prescribe To prescribe a medication in a patient note, call up the Prescribe form: Prescribe Now dictate your prescription medication. For example: Meclizine, 25 mg QID, quantity 30 NoteSwift enters the medication name and correct dosage and frequency. A list will appear in Aprima showing the medication found. Click on the correct medication in the list and choose OK. Another dialog will appear asking for acknowledgement and if you want to continue. Choose Yes. Click or say Done when you are finished with Prescribe.

26 25 NoteSwift for Aprima Plan Call up the Plan form say: Internal Notes Visit Notes Patient Instructions Exercise Return Visit Dictate each item s information. In the case of Exercise you can dictate recommended or restricted and then continue to dictate the exercise note. NoteSwift will automatically choose the proper radio button, either Restricted or Recommended. In the case of Return Visit you can dictate the length of the visit and NoteSwift will automatically choose from the Days, Weeks, Months and Years radio buttons. Internal Notes, Visit Notes, and Patient Instructions all use free form dictation and do not require any additional steps

27 Click or say Done when you are finished with Plan notes. NoteSwift for Aprima 26