Advanced Clinical Notes

Transcription

1 Advanced Clinical Notes Quick Guide Page 12 Add an AutoCorrect Entry to Speed up Typing Consider setting up typing shortcuts. For example, if you need to type sternocleidomastoid, why not just type s/c and press the spacebar - Word automatically spells out the word. 1. On the Tools menu, click AutoCorrect Options. The AutoCorrect dialog box opens. Make sure you are on the AutoCorrect tab. 2. In the Replace: box, type an abbreviation you will remember for example, s/c. (Notice we have included a slash simply to avoid this being a real word.) 3. In the With: box, type the complete spelling of the word for example, sternocleidomastoid. 4. Click Add and OK. 5. Now when we type s/c and hit the Spacebar, Word automatically changes the s/c to sternocleidomastoid. This is a useful tip to quickly type medical terminology. Add an AutoText Entry for Repetitive Phrases To store and quickly insert repetitive phrases, use AutoText. 1. Type the repetitive phrase. 2. Highlight the repetitive phrases (using Word s Selection Area). 3. Press Alt-F3 or choose Insert, AutoText, New. 4. The Create AutoText dialog box appears. 5. Word will pick up the first few words of your phrase and assume that is what you want to call it. 6. Click OK to accept or rename the entry (must be at least four (4) characters long because Word inserts an entry only after four characters have been typed). 7. Word stores the AutoText entry in its library. 8. Place your insertion point at the location where you want to insert the AutoText entry (phrase). Start typing the phrase. 9. A yellow box appears. If you want this AutoText entry to appear, hit Enter. If not, just keep on typing and the yellow box disappears. Advanced Clinical Notes QUICK GUIDE Last modified 2009/09/28 02:54:00 PM G:\C3\Advanced Clinical Notes\ACN Quick Guide Rev Oct 2009.doc

2 Advanced Clinical Notes Quick Guide Page 2 Getting Started 1. Open a patient s chart. REMEMBER: It is very important that you are on the correct encounter before you create a clinical note. Always verify that the Demographic Bar displays the correct visit information before proceeding. 2. If you are using PowerChart Enhanced View, click Clinical Documents/Reports from the menu. Advanced Clinical Notes Quick Guide Page11 3. Spell Check When setting up your Cerner options, if you set the option to Spell Check before Save, Word s spell check feature is automatically launched after you sign or save. Correct your spelling mistakes, add words to the custom dictionary, or ignore the suggestions, if necessary. Viewing the New Document 1. Once you sign or save the document, the system will ask you if you wish to view the newly created document. 2. Click Yes. 3. The document displays in the Clinical Documents/Report section of PowerChart. 3. If you are not using Enhanced View, click the Clinical Document/Reports tab. 4. Remember, when it s a Final Report, if you click the Modify icon from the toolbar, you will add an addendum to the end of the document (through Advanced Clinical Notes).

3 Advanced Clinical Notes Quick Guide Page10 2. On the Formatting toolbar, click the Outside Borders icon and then select No Border. 3. You are left with only gray gridlines, which show the table structure but do not display or print on the final copy. IMPORTANT: When inserting data from a document, e.g., Admission Note, remember to remove the banner information in your new document. Sign or Save your Document Once the document is complete, you may Sign or Save it. 1. Sign Option If you choose the Sign option, it authenticates and verifies the document as a Final Report and sends the document to all those identified as co-signers and reviewers (either through Message Center or by fax or mail). 2. Save Option If you choose the Save option, it posts the document as a Preliminary Report. In Message Center, a saved document is considered "In Progress" and can only be seen and modified by the author, co-signer(s) and reviewer(s). It is important to remember, then, that the In Progress document appears in the Sign folder in your Message Center as well as the Sign folder for those identified as co-signers and the Review folder for those identified as reviewers Advanced Clinical Notes Quick Guide Page 3 Copy from the Medicine Chart Summary Tab Do the following steps before you launch Advanced Clinical Notes: 1. Click the Medicine Chart Summary tab or component and highlight all of the text within the summary OR 2. Click the Medicine Chart Summary folder from the Clinical Documents/Reports tab or component and highlight all of the text within the summary. 3. Your must copy it to the clipboard using the keyboard shortcut of Ctrl-C there is no right-click functionality. Launch Advanced Clinical Notes and Create a New Document 1. Clinical Documents/Reports contains its own toolbar. 2. If you are using PowerChart Enhanced View, the toolbar is located within the Clinical Documents /Reports window. 3. If you are not using Enhanced View, the toolbar is located at the top of your screen (near the As Of icon). 4. From the toolbar, click the Add icon to launch Advanced Clinic Notes. 5. Advanced Clinical Notes opens to the Cerner Properties dialog box. 6. You need to set up the correct options for your documents the first time you access this function only.

4 Advanced Clinical Notes Quick Guide Page 4 7. Close the Cerner Properties dialog box by clicking the at the top right of the box. 8. From the menu bar, click View and then Cerner Options. Advanced Clinical Notes Quick Guide Page 9 4. When inserting lab work, the information inserts in a Word table. You can add and remove table columns and rows as needed. Remove Column 1. Highlight the column you wish to delete by placing your mouse over the top of the column until it becomes a black down-pointing arrow and then click with your mouse. General Configuration Tab Under the Processing Options section: 1. Uncheck Spell Check before Save if you do not want the system to automatically run spell check prior to signing or saving. Leave the option selected if you wish to have this feature active. (You are able to run spell check at any time you are creating a document.) 2. Uncheck Save Productivity Statistics. 3. Uncheck Print Document on Submit. 2. This highlights the column. Next, right-click and choose Delete Columns from the shortcut menu. Delete Row 1. Highlight the row you wish to delete by placing your mouse in front of the column until it becomes a white hollow arrow and then click with your mouse. 3. This highlights the row. Next, right-click and choose Delete Rows from the shortcut menu. Remove Border Lines There may be times when you do not wish to have the table border lines display or print. 1. Highlight the table.

5 Advanced Clinical Notes Quick Guide Page 8 Typing Your Document 1. The document window opens. Advanced Clinical Notes uses a Microsoft Word 2003 shell. The blue shaded areas are protected sections and display interface information from Cerner, i.e., demographic information report type, subject, signature line(s), etc. 2. You cannot edit a protected section by clicking into it with your mouse. If you find an error in a protected section, for example, a typo in the Subject line, you will have to click the Cerner Properties icon to display the Cerner Properties dialog box to make that change. 3. If you are not using a template, remember to type the document type you are creating in bold at the top of your document, e.g., Discharge Summary, Clinic Report, etc. 4. You are now ready to complete the body of your document. 5. You can type your information or you can paste from the Medicine Chart Summary tab (if you copied before launching Advanced Clinical Notes) and you can also insert patient data from the Flow Sheet tab of PowerChart. Paste Information from Medicine Chart Summary Tab When you wish to paste in the copied Medicine Patient Summary information, use the keyboard shortcut of Cltr-V, or right-click and choose Paste, or choose the Edit menu and select Paste. Delete fields that are not appropriate and add information as required. Insert Patient Data from Flowsheet 1. From the Insert menu, choose Patient Data from Flow Sheet. 2. Locate the information you require, such as lab work or a document. 3. For lab work, you may drag to highlight the area(s) of the flow sheet you wish to insert and then click OK. Advanced Clinical Notes Quick Guide Page 5 Processing Parameters Tab 1. In the Event Set, Preferred Event Set section, replace the default ALL DOCUMENTS SECTIONS with London ACN Documents. This must be typed exactly as illustrated. OLD NEW 2. In the Required Fields section, check Date of Service. 3. If you are a Resident, you must also check Co-Signer as a required field. 4. Click Save and OK. 5. You are returned to the transcription window; however, you need to open the Cerner Properties dialog box to continue. 6. Click the Cerner Properties icon on the toolbar. 7. Indicate the Document Type you are creating. You can click the Document Type button to see a list of document types. 8. OR when you start typing the first few letters of a document type name, the system auto completes the rest, e.g., if you type di, it will auto complete to Discharge Summary. 9. The Author field is automatically filled in. 10. Next, complete the Date of Dictation field. Remember you can use Cerner s keyboard shortcuts of t for today s date and n for the current time. 11. The Subject field is a freetext field that you can use to describe and clarify the document content.

6 Advanced Clinical Notes Quick Guide Page 6 DATE OF SERVICE FIELD IMPORTANT 1. Complete the Date of Service field (required). This is the date and time that the document posts to the Flow Sheet in PowerChart. 2. To post the document to the current date and time, use the shortcuts of t for today s date and n for the current time. 3. If you are creating a document for an event in the past, e.g., a Discharge Summary, set the date of service date and time to be as close to the discharge as possible. 4. Leaving the time blank will post the document to the date you indicate but at a time of 0000 hours. 5. If you wish, you can click the large down arrow to display a calendar from which to select the date. If you choose the wrong encounter (visit) when you select your patient, changing the date of service to the correct encounter date in the Cerner Properties box DOES NOT MAP the document to that encounter. You need to change the encounter date through the Patient field in the Cerner Properties box. TEMPLATE FIELD IMPORTANT Templates have been created for all document types and include pre-set headings, such as document type and patient location, to reduce errors and make typing your document easier. Look for templates that start with LDN for London. To jump between headings, use the keyboard shortcut of Alt-J. Advanced Clinical Notes Quick Guide Page 7 3. The Personnel quick pick: section automatically lists all personnel who have accessed the patient s record and their relationship with the patient. 4. To choose a name from the Personnel quick pick: section, simply click on the name and either click the Co-Signer(s) button or Reviewer(s) button to move them to the proper Participants: section. 5. If the person is not found in the Personnel quick pick: section, use the Personnel lookup: section to search. Enter the last name. If you do not wish to only filter for physicians, uncheck Physicians only. 6. If the systems finds more than one match for the name, always confirm that you have the correct provider by clicking the Preview icon to view more information, address, phone number, etc. CO-SIGNER FIELD IMPORTANT 1. If you are a Medical Student or Resident, you may author clinical documents; however, you must have a co-signer. 2. Always remember to complete the Co-Signer field with the name of the MRP (Attending). 3. If you are a Resident, you also have the ability to sign the document; however you may wish to review your workflow process with your Attending because if you sign the document, the Attending can then only add an Addendum to the Final Report copy. REVIEWER FIELD - IMPORTANT 1. Add Reviewers when you want a copy to be sent to another clinican. 2. For the Co-Signer(s) and Reviewer(s) fields, you may type in the last name or organization or click the Co-Signer(s) or Reviewer(s) buttons to open the Provider Look Up dialog box. 7. NOTE: For Ministry of Transportation, type only Ministry to select the correct office from a list. Alternatively, entering the entire Last Name, First Name (Ministry Of Transportation, London) will give you an exact match. 8. When required and other fields are complete, click OK. NOTE ABOUT REVIEWER COPIES All personnel who have Message Center will automatically have the document sent to them electronically through Message Center. External providers, such as family physicians, Ministry of Transportation, etc., will have the document faxed or mailed (on Final Report copy).