Clinical Notes and Letter Templates - Advanced

Transcription

1 Clinical Notes and Letter Templates - Advanced

2 Discussion Format Computer Classroom Format Lecture will be conducted throughout this session. We have a ton of content to share and everyone will be at a different level If you have a question, please raise your hand and the QHR Reps will do their best to come around and help you at your station Feel free to just listen and take notes, or use the time to work along with us on your system There should be time at the end for a group question/answer discussion

3 Overview Create a Note/Letter Template Select a patient from the Daysheet or TM Open the Template on the patient to create the Note Document the Encounter Generate the Letter

4 Definitions Template All notes technically start from a template. All of the items in your Clinical Note list come from the Template Wizard. They are starting points to save time when creating notes Macro Is a shorthand command that will generate predetermined text into any Note or Letter Clinical Note/Letter Can be created in the EMR > Encounter Notes Tab. Once saved, the note is then available in the Encounter Notes section and the Virtual Chart. This becomes the BODY of your Generated Letter Generated Letter The finished letter that will be used for communication outside of the clinic. It brings together all of the letter elements including the Body from the Clinical Note, Letterhead, Introduction and Footer Query Option to pull lab and medical history data from a patient s chart into the Clinical Note/Letter

5 Templates - Summary Create a Template Templates are created and edited in the Template Wizard from the Tools menu The Template Wizard is essentially a simplified version of a word processing program You will be using a combination of typing and right clicking to add tags that pull patient specific information Now, let s see this in action

6 Templates - Advanced An additional feature in Template creation is Bookmarks Bookmarks can be used to place a marker where you would like to type text Accuro places a small triangle in the Template to indicate where these markers are To navigate to each marker simply hold down the CTRL key and use your arrow up and arrow down keys

7 Additional Template Concepts Tags Macros Clickable Words Queries

8 Tags Tags are codes within templates or macros that pull data from Accuro To apply a tag, right click in the Template, then choose from the options Tags can come from several different areas within the patient s demographics and chart Once note or macro tags are pulled, they do not refresh the data

9 Macros Create a Macro Macros can also be created in the Template Wizard in the Tools menu (like Templates) Macros could be created Ad Hoc instead, when you are in a Clinical Note on a patient s chart, just highlight the text > Right click and choose Save as Macro

10 Macros - Summary Recalling Macros 1 -Type Macro Name -Press CTRL + ENTER -Your phrase will appear 2 -Right Click -Choose Find Macro Where to use Macros Clinical Notes Generated Letters Forms Messages and Tasks

11 Clickable Words Syntax [ dull sharp throbbing ] [ Start of a { formatted list Start of a non-formatted list Separation between the items in the list ] End of a formatted list } End of a non-formatted list null Special word that when selected, clears out the entire list

12 Clickable Words Clickable Words are a list of selectable options that you can use within Templates and Macros. Click the word(s) you want and the rest will disappear! Patient complains Patient of [dull sharp throbbing] complains of pain pain located in in the the neck. [head neck legs]

13 Clickable Words If you select multiple options within a formatted list, Accuro will include the conjunction needed to make the sentence grammatically correct Patient complains Patient complains of [dull sharp throbbing] of pain located pain located in the head in the and [head neck legs] neck.

14 Clickable Words - Summary Clickable words can be used when there are multiple options that could be selected in predetermined sentence to save time when typing Once your clickable word lists have been created, you can double click or use the Complete Selections button to make your choice Check this out!

15 Combining Macros and Clickable Words If you have a clickable words list in a template, you can set up the options to be macros so that once selected, you can apply the macros command (CTRL + ENTER) to expand the list Taking this one step further, your macro may even include additional clickable lists

16 Combining Macros and Clickable Words Clickable List Macro Regular Sentence Clickable List Option A Option B Expanded Macro Option A Expanded Macro Option B Expanded Macro

17 Queries Lab Queries Recent lab values and collections dates can be pulled automatically into notes and letters by using the Lab Query button in the Template Wizard

18 Queries Medical History Queries In the same window as the Lab Queries you can also pull the patient s current Medical History into your note or letter and choose the format in which it is displayed Remember Once note or macro tags are pulled, they do not refresh the data

19 Advanced User Tips To account for the Medical History data not refreshing after a template is opened, you could use a Macro that includes the Medical History Query which then can be applied at any time during the Encounter. Once triggered, the current Medical History would be inserted into the note/letter Let s try it!

20 Clinical Note Controls Formatting Toolbar Note Meta - Data Today s Medical History recordings including lab results

21 Clinical Note Controls From the Formatting Toolbar, there is an icon that allows you to Complete all selections from Clickable Word lists at once

22 Clinical Note Controls Also from the Formatting Toolbar, there is an icon that allows you to insert an image from your computer into any note Let s try one out!

23 Clinical Note Controls Date of Service (DOS) Within the note Meta Data, you will see the date of service attached to your clinical note. Clinical Notes are automatically linked to the appointment date when you select the patient from the Daysheet or highlight the appointment in the Encounter Notes tab before opening a Note Alternately, if there is not a DOS the note will either be linked to TODAY or a date that you choose The DOS can be changed at any time within the Clinical Note by using the drop down or the Calendar button

24 Clinical Note Controls There is also a title field within the note Meta Data Use this Title field to label your notes, as an option, so they show in the Encounter Notes Summary view and the Virtual Chart with a meaningful description of the Note The default is the title of the original Template

25 Lab Insertions On the fly, you can drag and drop values from the patient s lab results for the current visit while your Clinical Note is open

26 Lab Insertions On the fly, you can drag and drop values from the patient s lab results for the current visit while your Clinical Note is open. We can take this one step further and drag and drop values from the patient's full lab summary Look!

27 Options Menu Tablet Controls This places a row of buttons at the bottom of the note to insert punctuation Auto Capitalize Pasting/Sentences Good feature for those using voice dictation where the first letter is not auto-capitalized Configuring Auto Correct Edit the words that Accuro will autocorrect when misspelled

28 Advanced User Tips Configuring Auto Correct can be used to make Macro like phrases! Pick uncommon character combos that can populate whole sentences when typed

29 Advanced User Tips Did you know? You can add your own dictionary to Accuro, including a Medical Dictionary! You can either add Word by Word, OR Import a plain text file that contains each word on a separate line

30 Letter Generation In Accuro, you type the BODY of your letter in a template, then use the Generate Letter function to send it or print it

31 Letter Generation Components of a Generated Letter Letterhead Watermarks (Optional) Introduction Medical History button Body Footer Attachments

32 Letter Configuration We can configure most of the components of Generated Letters with: Tools > Providers (F2)> Configure We ll take a look..

33 Letter Generation Components of a Generated Letter

34 Letter Generation Introduction broken down: Recipient and Patient information Comes from Configuration in F2 Medical History This button configures the insertion of the patient s medical history into the letter. It will be included as part of the Introduction and appear directly underneath what has been pre-configured as the Intro There are dropdowns to determine the formatting of each chosen history item

35 Finalizing the Letter When you are finished editing your Generated Letter there are a few options for your next steps Print Add to Letter Queue Apply any changes made to the BODY of the letter but abandoning the letter generation Send Letter

36 Sending the Letter Referral Letters being sent out of the clinic can be tracked by ticking this box If the recipient has a fax number, Fax will be selected. If not, print will default as selected Send Faxes Later is used to flag the fax to be sent MANUALLY at a later time You can include a Coversheet message with your letter

37 Tracking Referrals All New Referral Orders are added to the Report Outstanding Requisitions, Referrals and Orders This report can be used to monitor the progress of the patients referral to another Physician Now we ll try in Accuro..

38 Viewing Past Letters Only once the letter is sent or printed, a copy of the finished letter is saved in the Virtual Chart as a Generated Letter

39 Audit Trails Accuro tracks all saved changes to notes Under Tools in the Clinical Note, there is Previous Versions and Letter History Let s see it work!

40 Audit Trails Previous Versions Viewing changes opens in a new Clinical Note window for each past version Letter History Opens in a new window highlighting changes since last save point Snap shot of the Clinical Note at that specific save point Can view changes from multiple save points without opening a new window Allows you to Save As to create a new note from the selected save point Information cannot be edited, only printed

41 Audit Trails You can prevent changes to notes by locking them

42 Audit Trails You can prevent changes to notes by locking them There is also a System Setting to automatically lock your notes after a predetermined amount of time

43 Summary You can create Templates and Macros to be used in the EMR in Accuro Templates are more structured Macros can be used on the fly Once the Template is opened on a patient, there are several options to make typing the encounter faster Using Macros within Templates Clickable Lists Inserting images and lab values Your note can be generated into a letter that will be sent outside of the clinic, with tracking! There are options to track your work and changes to help ensure you won t lose any information

44 THANK YOU