Trainer Outline: Provider: Documenting a Visit with Note Capture Prerequisites Please reference the OP15 Resource List ILTs: All Roles: Navigating the Electronic Chart All Roles: Messaging Who Needs to Attend All Providers Maximum group size: 3 (unless prior approval) Objectives Start the Visit Review Health Maintenance Notifications Review Active Items Review the Problem List Review Medical History Recent Encounters, Vitals, Allergies, Medications, Histories, etc. Document the Exam with Note Capture Document the Assessment and Plan with Note Capture Create an Order Write a Prescription Provide a Handout Request a Follow Up Preview and Finalize the Note Addend a Note Delete a Note if created in error Learn where to find your notes later 1
Trainer Prep Create one appointment: Appt for sore throat Set Encounter Purpose to Appointment Make sure test patient to be used has a preferred pharmacy Stage allergies and meds, plus previous vitals Have at least 1 problem in the problem list Stage a Note in Active Items: Review how her new medication regimen is going Check with implementation that the client s solution has at least one template tagged so that an associated template will auto populate on launching Note capture Trainer Gotcha: Based on the practice s specialty, you will need to adjust the scenarios. The suggested scenarios in this outline are for primary care. 2
Task Scenario Start the visit 1) Start a sore throat visit for an established patient with a scheduled appointment Review Health Maintenance Notifications Demo/ Hands on Activity (Client Expectations) Key Concept 1. From the Appointment list, change the encounter status to With Provider The chart opens by default with encounter information populated. 1. Review Health Maintenance Notifications Health Maintenance is configured per practice. The Guidelines track what the patient is due for based on things like diagnoses, vitals, demographics, medications, etc. Backpocket: There is a standard set of eight that are configured for MU clients. These meet the requirements of Clinical Decision Support Interventions. Please direct them to the Help & Training website for more detailed instructions on this objective. 2. Click Dismiss All Review Active items 1. Open Active Items tab 2. Review Chart Notes Backpocket: This is a threaded content object. 3. Review documents and messages requiring review This tab allows providers to see any kind of document that has not been completed. Chart Notes: Text box where providers can type reminders for themselves for the next encounter (eg. Remember to run this lab test next time the patient comes in) Documents with Pending Action: typically contains lab results. Review Problem List 1) Add a new problem 2) Mark Problem List as Reviewed We will cover the Problem List in detail in a separate session. Note that there are also detailed videos regarding ICD 10 and the Advanced Diagnosis Search available on the Help & Training website. Scenario 1: Add a new problem 1. Mark as Chronic, if applicable 2. Start to type seizure in Problem Name field and select. When you start typing the diagnosis, it will automatically start auto matching. 3
3. Choose Seizure 4. Select one filter to narrow down the choices, then choose the code/description. 5. Click Done 6. Modify diagnosis date if necessary Diagnosis date defaults to today 7. Modify Treatment Status = Controlled Treatment status defaults to not specified 8. Type treating provider = outside provider Treating provider can type a provider name in the practice, type the name of an outside provider, or leave blank (if logged in as a provider, your name will default). Note: If the problem is not related to today s visit, click drop down and remove from today s encounter. Scenario 2: Mark Problem List as Reviewed 1. Mark Current Problems as Reviewed Marking the Problem List as Reviewed allows you to track who reviewed the information and when. Clicking history will display a report of when users reviewed the information. Note that information marked as reviewed aren t marked as reviewed in the progress note. Reminder: We will cover the Problem List in detail in a separate session. Note that there are also detailed videos regarding ICD 10 and the Diagnosis Advanced Search available on the Help & Training website. Review patient history 1) Review Histories 2) Review recent encounters 3) Review Vitals, Allergies and Medications Scenario 1: Review Medical/Surgical/Social/Family history information recorded by the clinical staff 1. Go to the History tab and click each History item 2. Click mark as reviewed Scenario 2: Review recent encounters 1. From the History tab, review Visits to see previous encounters If available, there will be a link to open the progress note from the encounter in the far left column. Scenario 3: Review Vitals, Allergies and Medications recorded by the clinical staff 1. Go to Encounter/Enc Tasks tab This information can also be reviewed in each of the individual tabs. 2. Review Vitals Today s Vitals will also display on the progress note. 3. Mark as Reviewed (optional) 4. Review Allergies 4
Trainer Gotcha: s how providers that they can see their Allergies on the Patient Banner (based on the user option "Allergy Default View" being configured during implementation) 5. Mark as Reviewed (optional) 6. Review Medications Notifications indicate if a medication should be course completed. Be sure to mark complete when the patient has finished the medication so that the medication will be moved to the past medication list (found in the Medications tab) 7. Mark as Reviewed (optional) 8. If applicable, review the Immunization Summary on the Immunization Tab Begin Note capture 1. Click on Note Action Link 2. The Begin Encounter Documentation window will open Encounter purpose defaults from scheduled appointment but can be modified. Encounter note output (aka template) is selected based on encounter purpose. This key functionality drives what data will output on a note, and what document type will be created. Reason defaults from the appointment. Chief complaint, if not added by nurse (in chief complaint or Vitals content object in the Encounter/MA Tasks tab), will default based on the appointment reason. The provider can edit the chief complaint in this window or in Note capture. In this window we see the patient's current problems. Check the box next to any Problem you wish to include in today's visit. Trainer Gotcha: If tags are set up on templates that match the reason or chief complaint, it will automatically load that VISIT template. If there is more than one template that includes that tag, you will be prompted to select which Visit template you want to use (it will be Suggested) 3. Click Next The Note capture window allows the user to document the chief complaint for the encounter, history information, visit notes, add diagnosis or existing problem to the encounter, and the plan to address the problems. You may want to expand it to your full window by clicking the boxes in the upper right corner for more workspace. Appointment note capture is designed to display the patient s chief complaint and history information from their chart. You can edit the Chief Complaint by clicking on it. You can edit any of the Histories by clicking on the Pencil icon. Trainer Gotcha: Not ALL Encounter Purposes will load Chief Complaint, and Histories; this is controlled in 5
Scheduler Encounter Purpose control panel if it does not appear, it is because those pieces are disabled Document Exam 1. Notice that the template may load automatically, or you can select it from the list 2. Click on a few of the choices in the HPI phrase to get a feel for how it works Black text, text boxes and selected items (green) will be seen. Create your narrative: Words in solid black are always displayed. Words that are greyed out will not be seen. Words that are green will be seen. Depending on the template, you will be able to select one or multiple choices. There could be a phrase picker configured within the note that will allow the provider to choose additional phrases. Trainer Gotcha: If the solution has Removable Bullets, when you click remove Removable Bullets, you cannot bring that section of the phrase back (it removes it from this specific note). 3. Click Preview button to see how note is constructed 4. Click Return to Note 5. Click on drop down below HPI 6. Add Text Area 7. Do pertinent positives and negatives in ROS section (tri state) 8. Utilize the phrase picker to add another system to your exam. 9. Click on right arrow at end of list and add another phrase to the existing list This is called a Dynamic Item. It will only appear in this specific note. 10. Click on a few choices in Physical Examination section Vitals are shown at the top of the Physical Exam section and can be edited if needed. Document Assessment and Plan 1) Load overall plan and order in office Strep test. 2) Test was positive. Document diagnosis and Plan Write a prescription Provide a Scenario 1: Load a plan and order an In Office Strep test 1. Select overall plan 2. Order In Office Strep test a. Click to expand In Office Orders b. Select Rapid Strep Ordering will be covered in more depth in another session Scenario 2: Document the Diagnosis and Plan 3. Document the Diagnosis by selecting from the Medical Decision Making section (if configured) or by clicking the Diagnosis Lookup button a. Search for Streptococcal sore throat b. Select one filter to narrow down the choices, then choose the code/description 6
Handout Request a Follow Up Create and finalize note c. Click Done Reminder: We will cover how to manage Problems in detail in a separate session. Note that there are also detailed videos regarding ICD 10 and the Advanced Diagnosis Search Diagnosis Advanced Search available on the Help & Training website. If you accidentally add a problem, then remove from the encounter, you must also go to the problem list and remove the problem selected in error. Diagnosis chosen will result in three actions: the problem will be added to the note (may also load a plan depending on how the solution is configured), problem list, and charge slip. If the problem didn t match any tags, then it will load the default plan. 4. Click on Sore Throat Prescriptions paraphrase (IF Medication Favorites have been configured in the plan; if not, click on the Prescribe Action Link) a. Amoxicillin 500 mg TID x 10 days 5. Provide a Strep Throat Handout a. Add either via Paraphrase (IF Handouts have been configured in the plan) OR b. by going to the Handouts Content Object, based on the solution configuration 6. Request a Follow up in two weeks using a Paraphrase (IF Follow Ups have been configured in the plan; if not, it can be created from the Charge Slip) 1. Click on Create and Edit button You can only edit from Create and Edit button, cannot edit from Create and Finalize. In Edit mode, you can interact with the Note much like you would with a Word document. Other options include: a. Save: Saves your work and allows you to continue editing (OP auto saves on a regular basis also) b. Save and Close: Saves your work and closes the note but you can come back to edit it later c. Preview: Previews what the note will look like once created d. Create and Edit: Creates the note in edit mode e. Create and Finalize: Creates the note and automatically signs and finalizes 2. Click on Signature button to Sign and Finalize the Note Addend a Note 1. From the finalized note 2. Click on the Addend Progress Note button (yellow sticky note with a red push pin) NOTE: If you highlight text prior to clicking Addend, it will strike out the text and allow you to insert the new text at the cursor. 3. Enter text into addendum field 4. Choose to Insert at Cursor or Add to end of the note 7
5. Click Addend Progress Note Delete a Note if Created in Error Learn where to find your notes later If you create a note in error or the note needs modification beyond attaching and addendum, you can delete the finalized note and return to note capture 1. From the finalized note, click the options button in upper right hand corner (blue square w/ white plus sign) to open your options menu 2. Choose Delete this document 3. Confirm document deletion in window by entering in the reason for deletion 4. Click the Delete Document button This deletes the finalized note and returns you to note capture 1. Go to Dashboard > Provider > Progress Notes This will be covered in more depth in the Dashboard session Progress Notes can also be found in the All Documents Tab of the patient s Chart, or the Visits Content Object. Back Pocket: There is also an Encounter Missing Notes report in the Reports workbar This report is designed to show every encounter that does not have a note created. This is also covered in more depth in the Dashboard session. 8