Creating a Documentation Template

Transcription

1 Creating a Documentation Template Faculty, thank you for taking the time to learn how to build your own documentation templates and notes in the Neehr Perfect EHR. This Guide also acts as a step-by-step tutorial. Completing this activity will help you better understand how to create your own template. Creating a documentation template is a 2-step process: 1. The template is created 2. Neehr Perfect publishes the template for your student s to use as a progress note in the EHR Note: The screen shots in this Guide will vary based on what is being explained. Terminology Boilerplate: The work area for building the contents of a templated note. When documenting in a templated note,the templated portion is the boilerplate. See page 3 for how the Boilerplate is used when building templates. Note: Sometimes called template or electronic note. The note relays valuable information of the patient, their visit, their health or health care need. The note is often the finished product when a provider documents in a template. In Neehr Perfect, the student and faculty document in notes by going to the Notes tab and choosing New Note. Notes can be templated or untemplated. Template: Sometimes called a documentation template. In the EHR it is a document with instructions, predefined documentation choices, and/or narrative documentation in a format that has not been produced as a note yet. Documentation templates can play an important role in improving the efficiency of data collection, ensuring all relevant elements are collected in a structured format. A template can be in a note. Template Fields: Allow you to document in predefined text edit boxes, combo boxes, buttons, check boxes, or radio buttons. There are thousands of template fields in the EHR. They can be created to fit specific needs when developing a template. Step-by-step tutorial 1. Open any Practice chart. Go to the Notes tab > Options > Create New Shared Template. On the right side under Personal Templates,enter the title of the template you are wanting to create. Personal Template Properties Name: You can name the template whatever you would like at this point. For example, SCHOOL ASSESSMENT or SMITH,MARY TEMPLATE. See the example below. NOTE: When you are ready to publish your template as a note for your students to see, you will need to contact Neehr Perfect to have your template title added. teaching@neehrperfect.com 2. You will see the title you just entered now showing in Personal Templates > My Templates. Leave the Template Type as Template. This will be a simple template, not unfolding. Click on Apply. You will be creating the actual documentation template in the Template Boilerplate. 1 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

2 Tips to creating a template In the EHR, you can use the step-by-step comprehensive Help tool by clicking on the Help menu > Index > and then typing in Template. You are only allowed so many characters across (horizontally) the maximum is 80 characters. Look at the Column: to know where you are at. There is no bolding, underlining, coloring or italics like in a Word document. o To underline or add a divider, use repeated dashes, equal signs, or asterisks (------, =====, ****** ). Look at other templates to see how these symbols are used. Click on Apply frequently to save work. If you click OK or Cancel and have not saved your work it will be lost and it cannot be recovered. You can copy and paste from another document (such as a Word document) or within the Template Boilerplate. In the Tools Menu of the Template Editor you are able to Create and Edit Template Fields. It is proper EHR etiquette to not look at or change other users work in the EHR. In the Shared Templates folder to the left you are able to see other templates that are being worked on or are under construction. Do not edit or work on any template other than your own. 2 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

3 Highlight your template. 3. Begin creating your template by typing in the Boilerplate area the following information from the screen shot. Use all caps and enter into your template just as it s shown. Notice as you enter the information how the Line and Column numbers change. Tip: Your template must be highlighted in order for you to document in the Template Boilerplate. You are typing in the Template Boilerplate. Click on Apply frequently to save work. 3 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

4 Template Fields allow you to create text edit boxes and lists of text that can be selected via check boxes, radio buttons, or combo boxes. These controls can be added to the template. The asterisk (*) denotes a required field and requires the user to complete all required fields before exiting a template. A message will display at the bottom of the template to the user: * Indicates a Required Field. The Template Field Editor provides the functionality of creating new template fields. In the screen shot below of a completed template, the Template Fields are highlighted. As you can see, Template Fields are used for just about everything. 4. Enter the following Template Fields. The first one is shown below. a. Place curser where you want the Template Field to go. After PATIENT AGE: enter a space and with your mouse right-click. Click on Insert Template Field. 4 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

5 5. Type in the letters EBOX. This is an abbreviation of edit box. It defaults with the list alphabetically. Highlight and select EBOX03. This means this edit box allows free-text for up to 3 characters. Thinking that no ones age in years will be above a 3-digit number this is a good choice. Type in Select 6. Once you have highlighted EBOX03, click Preview to see what the template field will look like. You can even test it by entering text. You may even Preview what text you are testing. Once you are done with the Preview Template Field click OK. 5 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

6 7. Then choose Insert Field > Done. 8. Repeat the steps and fill in the Sex and Date of Admission. a. Sex: (space) right-click > Insert Template Field > type in Male > choose MALE/FEMALE that is a Button > Insert Field > Done. b. Date of Admission: (space) right-click > Insert Template Field > type in Date > choose DATE REQUIRED that reads *Date > Insert Field > Done. 9. See how you are doing so far - but click on Apply first! Place your curser in the Boilerplate > Right Click > Preview/Print Template. Test the template if you would like. Preview also! When you are done click on Cancel to go back to the Boilerplate. 10. Continue building the template. a. Marital Status: (space) right-click > Insert Template Field > type in Marital > choose MARITAL STATUS LIST that reads Check Boxes > Insert Field > Done. b. Click Apply! 6 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

7 11. For Employment Status and Insurance you will build new template fields to go into your template. You will do this next. Creating a Template Field Below is an example of a template field editor. The top screenshot is from the Neehr Perfect EHR. The second screen shot is from the VA EHR. The left side of the screen ( Template Fields ) shows the many template fields that have been created and saved and are available for users to choose from as they design their own template. At the right is the contents of the template field. As you can see there are different types of template fields and ways to set up the field to act or to look a particular way. Commonly Used Template Fields Checkboxes multiple selections can be made from a list. The list can be vertical (separate lines) or horizontal. Radio buttons only one selection can be made from a list. The list can be vertical (separate lines) or horizontal. Edit box select a number to designate Field Length and Text Length. Date date field. There is also the option for Date and Time. Word Processing - select a number to designate Field Length and number of lines. Text items in this field can be for display purposes and excluded from note. Number lists numbers only. The options are difficult to read, this is due to the computer screen resolution. There is no need to change your view! You can expand the screen to get a slightly better view of the options. They are OK, Cancel, Apply and Preview (in that order). In the next screen shot you will see a more clear view of the Template Field Editor. 7 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

8 12. Click on the Tools menu and select Edit Template Fields. 13. At the Template Field Editor pop-up (below), click on New and enter the following New Template Field name. a. Name : EMPLOY Your initials, a space, then a 2-digit number. For example, EMPLOY MS44. The EHR will not allow two template fields to have the same exact name. By you using your 2-letter initials, and a 2-digit number, there is a better chance of not having a duplication among you and your classmates or other users of the EHR. b. Then click on the Type box arrow > choose Combo Box. If you get a pop-up that reads Field Name is not unique, this means the name you entered already exists in the EHR. Just click OK and change your 2-digit number to something else. 8 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

9 Type here. This template field can be used to Search through all of the templates. c. Build the contents of the template field. Enter the Items you see below in the next screenshot (Not employed, Full-time, etc). d. Click Preview to see what the template field will look like in the template (documentation note) itself. Click on Cancel to get out of the Preview. e. Then Click Apply to save your new template field. 9 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

10 This is Preview! This is Apply! 14. Repeat the above steps from #13 to add another template field for the Insurance entry. 15. Click on New at the top of the Template Field Editor. 16. Use the same naming scheme as you did with EMPLOY, but use the word insurance this time, INSURANCE MS Build the contents of the template field. Enter the Items you see below in the next screenshot (Private, Self-Pay, etc.). a. Click Preview. b. Then click Apply to save your new template field. 18. Click OK to leave the Editor. 10 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

11 Your initials & numbers. This is Preview! This is OK! This is Apply! 19. Back at the Template Boilerplate, follow the above steps (#4 - #10) to enter YOUR Employ template and YOUR Insurance template (the two template fields you just created). Make sure you choose the one with your initials and number. 20. Click Apply. 21. Preview your template > Close out of the Preview by clicking Cancel. 22. Do not close the Template Editor! 11 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

12 To publish your template for student use 23. Do not close the Template Editor! 24. Highlight your Personal Template and drag and drop your template into the word Shared Tamplates. It is a folder and your template will be dropped into the folder. 25. Click Apply! 12 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

13 Notice on the Notes tab that there is a Templates bar and a New Note bar. To get the template you just completed published for use by students it needs to be moved to the New Note option. In Neehr Perfect, the use of Shared Templates from the Notes page is avoided because of the high-risk of modifications to templates. Think about it, if you have access to it and wanted to make changes to a template you could! Multiply that by all of the students and faculty using Neehr Perfect! So, because there are thousands of students and faculty using Neehr Perfect, the templates (or notes) used on a regular basis are kept in a safer location. By keeping notes and templates in the New Note area prevents accidental or intentional modifications. 13 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2

14 26. Barbara Smith at Neehr Perfect, In the explain that you have created a template and that you need a title for it for student use. Give Barbara the name of the template you created and the title you would like. 27. Once Barbara has received your she will let you know when the note will be ready for student use. This usually only takes a few days. The note you created will be moved from the Shared Templates folder to the Documents folder. Then from the back-end of the EHR your title will be created and your note will be published for use, and will be searchable, when student s select New Note. If you have any questions or would like a 1-hour training on how to create your own templates, please contact Neehr Perfect at teaching@neehrperfect.com. 14 Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2