for Allscripts Professional EHR

Transcription

1 for Allscripts Professional EHR Tips and Tricks to get the most out Allscripts Professional EHR August 24, 2015 NoteSwift, Inc. One Boston Place, Suite 2600 Boston, MA,

2 ii Copyright NoteSwift, Inc. All Rights Reserved. NoteSwift is a trademark of NoteSwift, Inc., in the United States or other countries. All other names and trademarks referenced herein are trademarks of NoteSwift, Inc. or their respective owners. Designations used by third-party manufacturers and sellers to distinguish their products may be claimed as trademarks by those third-parties. Dragon Medical Practice Edition and PowerMic are registered trademarks or trademarks of Nuance Communications. Nuance OCR 2015 Nuance Communications. All Rights Reserved. Allscripts and the Allscripts logo are either registered trademarks or trademarks of Allscripts, in the United States and/or other countries. The MIT License Copyright (c) 2007 James Newton-King Permission is hereby granted, free of charge, to any person obtaining a copy of this software and associated documentation files (the "Software"), to deal in the Software without restriction, including without limitation the rights to use, copy, modify, merge, publish, distribute, sublicense, and/or sell copies of the Software, and to permit persons to whom the Software is furnished to do so, subject to the following conditions: The above copyright notice and this permission notice shall be included in all copies or substantial portions of the Software. THE SOFTWARE IS PROVIDED "AS IS", WITHOUT WARRANTY OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO THE WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NONINFRINGEMENT. IN NO EVENT SHALL THE AUTHORS OR COPYRIGHT HOLDERS BE LIABLE FOR ANY CLAIM, DAMAGES OR OTHER LIABILITY, WHETHER IN AN ACTION OF CONTRACT, TORT OR OTHERWISE, ARISING FROM, OUT OF OR IN CONNECTION WITH THE SOFTWARE OR THE USE OR

3 iii OTHER DEALINGS IN THE SOFTWARE. Cryptolicensing for.net Copyright LogicNP Software. Microsoft Public License (Ms-PL) This license governs use of the accompanying software. If you use the software, you accept this license. If you do not accept the license, do not use the software. 1. Definitions The terms "reproduce," "reproduction," "derivative works," and "distribution" have the same meaning here as under U.S. copyright law. A "contribution" is the original software, or any additions or changes to the software. A "contributor" is any person that distributes its contribution under this license. "Licensed patents" are a contributor's patent claims that read directly on its contribution. 2. Grant of Rights (A) Copyright Grant- Subject to the terms of this license, including the license conditions and limitations in section 3, each contributor grants you a non-exclusive, worldwide, royalty-free copyright license to reproduce its contribution, prepare derivative works of its contribution, and distribute its contribution or any derivative works that you create. (B) Patent Grant- Subject to the terms of this license, including the license conditions and limitations in section 3, each contributor grants you a non-exclusive, worldwide, royalty-free license under its licensed patents to make, have made, use, sell, offer for sale, import, and/or otherwise dispose of its contribution in the software or derivative works of the contribution in the software. 3. Conditions and Limitations (A) No Trademark License- This license does not grant you rights to use any contributors' name, logo, or trademarks.

4 iv (B) If you bring a patent claim against any contributor over patents that you claim are infringed by the software, your patent license from such contributor to the software ends automatically. (C) If you distribute any portion of the software, you must retain all copyright, patent, trademark, and attribution notices that are present in the software. (D) If you distribute any portion of the software in source code form, you may do so only under this license by including a complete copy of this license with your distribution. If you distribute any portion of the software in compiled or object code form, you may only do so under a license that complies with this license. (E) The software is licensed "as-is." You bear the risk of using it. The contributors give no express warranties, guarantees or conditions. You may have additional consumer rights under your local laws which this license cannot change. To the extent permitted under your local laws, the contributors exclude the implied warranties of merchantability, fitness for a particular purpose and noninfringement. VcCom API Copyright 2015 Alan MacAree, All Rights Reserved. Citrix and Citrix XenApp are trademarks of Citrix Systems, Inc. and/or one or more of its subsidiaries, and may be registered in the United States Patent and Trademark Office and in other countries.

5 1 Contents Copyright... ii First Things First... 3 Assumptions:... 3 About This Document: Typographic Weirdness and Helpful Info... 4 Download and Installation... 8 Creating a NoteSwift User NoteSwift in a Remote Desktop (RDP) or Citrix Environment NoteSwift Windows Reason for Visit History of Present Illness (Reason for Visit) Other Commands Available in the HPI Window: Creating an Alias Creating aliases for ROS Template and Exam Template Creating aliases for other NoteSwift forms Documenting the Review of Systems Using a Template in the ROS window: Review of Systems Past Medical History Social History Family History Allergies Medication History Documenting the Physical Exam Physical Exam Assessment More about navigation in Assessment Plan Setting Default Target for the Plan window Prescribe Dictation... 63

6 2 NoteSwift Menus and Options Options General Unity HPI ROS PMH (Past Medical History) Exam Plan History Dictation Users Importing / Exporting Aliases Help Appendix A: Command Cheat Sheet... 75

7 3 Introduction First Things First 1. Do you have Dragon Medical speech recognition software installed? 2. Do you have Allscripts Professional EHR installed? 3. Do you have NoteSwift installed? If you can answer yes to all three, then proceed to training! If you need to install any of the programs listed above, do so before proceeding. Assumptions: This document assumes 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.

8 4 About This Document: Typographic Weirdness and Helpful Info There are certain typographic conventions in this document, which, once you learn them will help with 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. Additional command alternatives will be listed in parentheses (). 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. This causes NoteSwift to auto-jump to the next field in a NoteSwift window. If the NoteSwift window has a Next button, it allows entry of more than one listed item (such as in the Allergies, Medications and Social History sections of Allscripts Pro). Say or click Next to add each item into your window. When finished, say or click Done or press the Next hotkey (see below) to enter all information into the form.

9 5 If you are using a PowerMic hand held microphone, you have the ability to define hotkeys. The PowerMic II uses the defaults below. Find this dialog by clicking on Tools on the Dragon bar, then Options, then click on the PowerMic II tab. You can find more information on how to set your hotkeys in your PowerMic II and Dragon Medical documentation.

10 6 NOTE: In this manual, wherever you are asked to say Next or Done, you may also use predefined hotkeys on a microphone or your keyboard to accomplish the Next and Done functions. The Good Doctor icon. Whenever you see this icon, it means we have some important and helpful information for you from the Good Doctor himself, Dr. Chris Russell, founder of NoteSwift. These tips and processes will help you learn best practices when working with NoteSwift and your EHR. Here is your first tip from the Good Doctor! A Next hotkey can be assigned through the NoteSwift Options menu (image below) as well as through the PowerMic options (Image previous page) found in Dragon Medical. These are not mutually exclusive; you may have a Next hotkey both on your keyboard and your PowerMic. Important: make sure that if you choose a new Hotkey, that it isn t already assigned to a Dragon function!

11 7 Before using NoteSwift, go the Dragon Toolbar. Select Tools->Options->Miscellaneous, and uncheck the Voice-enable menus, buttons, and other controls button: Make sure this is unchecked.

12 8 Download and Installation IMPORTANT! If you access your EHR via Windows Remote Desktop (RDP) or Citrix, The NoteSwift Server component must first be installed and configured on the RDP or Citrix XenApp server where Allscripts Professional resides. For more information, refer to the NoteSwift Remote Desktop Installation Guide. The following software installation information is strictly for installing the NoteSwift desktop client. It is the same installation whether you are using it as a thin client for Remote Desktop, or a full client supporting a local Allscripts client installation. It will function with both a local Allscripts Professional client, and a Remote Desktop or Citrix session, depending on the profile you select at runtime. To download NoteSwift on your computer, enter the download URL that was provided to you. A dialog appears asking whether you d like to run or save the file. Select Run. If your browser does not give you this option, you will find the file downloaded into your default downloads directory. Double-click on the file to start the installation process. The Welcome dialog appears. Click Next.

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14 10 Accept the End User License Agreement terms and click Next.

15 11 You will be asked if you will be running your EHR via Remote Desktop (RDP) or Citrix. Select the correct option and click Next.

16 12 You ll be asked to specify the install directory for NoteSwift, the default is recommended:

17 13 At the next dialog, select Install to install the software:

18 14 You ll see a status dialog showing installation progress, and then a final window when the install successfully completes: Click Finish to end the installation and start NoteSwift for the first time. You ll see the NoteSwift program, which looks like this: Once you have created and/or selected a user profile, you can minimize the NoteSwift application during operation. If you chose Yes to install the Remote Desktop components, you will be asked to reboot your system before running NoteSwift.

19 15 Creating a NoteSwift User To create a new user for NoteSwift, you open the NoteSwift program. Click on the Add button Enter the user name Select the EHR Select the version of your EHR. Click Done IMPORTANT! If you are running NoteSwift in an RDP or Citrix environment, make sure you select Allscripts Professional (server) as the EHR. RDP and Citrix users should first start their remote EHR session (which should be configured to start the NoteSwift Server at the same time) prior to running NoteSwift on the desktop.

20 16 You will now see the user you added in the listing of users for NoteSwift. Highlight the appropriate user and then click Open. This opens the specified NoteSwift user. To edit a user s information single click on the user. Click on Change, and edit the information as needed. When finished click Done.

21 17 Select a patient and initiate an encounter within Allscripts Professional EHR. You are now ready to dictate a note using NoteSwift. You may start from any window, such as the Face Sheet or Patient Manager. NoteSwift in a Remote Desktop (RDP) or Citrix Environment If you are running your EHR via Remote Desktop, your administrator will have previously set up the link with the appropriate startup procedure for you. The correct order for starting NoteSwift in this environment is to first load your EHR, which will also silently launch the NoteSwift Server. You then start the NoteSwift application from your desktop (making sure that Dragon Medical is also running prior to launching NoteSwift). You should see the following icons on your Windows taskbar: NoteSwift desktop application NoteSwift Server Allscripts Professional EHR Notice that there are two NoteSwift icons: one for the NoteSwift Server which is launched when you start the remote session with Allscripts Pro, the other for the NoteSwift desktop application. Both must be running in order for NoteSwift to operate. (RDP users: notice that there is a small circular graphic on the icons that indicate the programs that are running remotely on the remote desktop server.) If you click on the icon representing the NoteSwift Server, the server window will be displayed, which looks like this: Status messages are displayed here Server Restart button see below! The server is launched minimized, and you would not normally have a need to view it during operation, it can stay minimized, unless you need to view it for troubleshooting purposes.

22 18 If you should attempt to close the NoteSwift server, you will get a warning: Unless you are asked to do so, you should choose No. Closing the NoteSwift Server while in operation will prevent NoteSwift from working with your EHR session. If this happens, restart your EHR session and the NoteSwift desktop application in order to continue. If you do encounter an error with NoteSwift, bring up the NoteSwift Server by clicking on the taskbar icon (where you should see an error message in the dialog window), and click the Restart button. You can then minimize the NoteSwift server window. Exit and restart the NoteSwift desktop application in order to continue working with NoteSwift.

23 19 NoteSwift Windows NoteSwift allows you to dictate free text narrative and structured data, where NoteSwift does the searching for you from a defined list. In this document we go through the NoteSwift windows and show you how to create the patient note whether you need free text or structured data. NoteSwift Windows covered in this manual are: Reason for Visit History of Present Illness Review of Systems ROS Template Past Medical History Social History Family History Allergies Current Medications Physical Exam Exam Template Assessment Plan Prescribe NoteSwift also has commands for Travel History, Surgical History, Pregnancy History, Diagnostic History, Health Maintenance and Dictation. These commands are similar to documenting the Social and Family History. See the NoteSwift Command Cheat Sheet at the end of the manual for a complete listing of the NoteSwift commands.

24 20 Reason for Visit Call up the Reason for Visit window. Say Reason for Visit The Allscripts Professional Reason for Visit details window and the NoteSwift Reason for Visit windows appear, allowing you to dictate complaints, categories, findings, values and descriptive text. The default EHR target (My Short Lists / Short Lists) is automatically selected. In this example, My Short Lists is the default, and there are three short list folders available. (You can learn more about setting the default tab in Allscripts Professional by referring to the Caregiver Options section in the Allscripts Professional EHR Clinical Module User Guide). If you want to work with a different tab, you can say the tab name (Previous Complaints, My Short Lists, Short Lists, Master List) and NoteSwift will select that tab. Once you are in the desired tab, the NoteSwift cursor is positioned in the Complaint field. To open a folder (a Short List item called NoteSwift Clinic was created for this tutorial), say NoteSwift Clinic NoteSwift will automatically select and open the folder, revealing its contents.

25 21 Note that the Complaint field has been cleared, and the cursor placed there again. This allows you to dictate one of the complaints within the folder. If you have folders inside your Short List item, you can say Open <folder name>, and NoteSwift will open that folder revealing its contents. If you are working with the Master List, NoteSwift also provides two power commands you can use: Search for, and lookup that allows you to use the Allscripts search function to find the desired complaint. Say Search for (or lookup) bronchitis from the Master List for example, to quickly find and select bronchitis. You can also say Clear Search to clear the search window and initiate another search. Say Bronchitis The Allscripts Professional details window appears for Chronic bronchitis.

26 22 Say Symptoms To reveal the findings and values for the Symptoms category. Say Cough To enter this information, and continue adding additional findings, say Next Finding The finding for Cough will be entered, and NoteSwift is ready for you to dictate the next finding for Symptoms. Say Wheezing, Next Finding Remember that the comma means to pause, allowing NoteSwift to auto-jump to the next field. You dictate it as: Wheezing <pause> Next Finding.

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28 24 The default for findings is Positive. To change to a Negative finding, say Negative Now, say Shortness of Breath, Next Finding You ll see that the X was selected for Shortness of Breath, indicating a negative finding. Say Hemoptysis Notice that the Negative option is still selected in the NoteSwift window. It will remain set to Negative until you dictate Positive again. If you wish to enter free text in the note field for any finding, say Note NoteSwift moves the cursor to the Note field in the NoteSwift window. Say Sputum is clear Move directly to any NoteSwift field by simply dictating the field name, such as Note. This is also useful when you would like to go back and change your input for a given field, such as Finding. To enter a negative finding for Hemoptysis and then move on to enter data in a new category, say Next Category

29 25 NoteSwift has entered the negative finding and free text for Hemoptysis, then positioned the cursor at the Category field, ready for you to dictate findings in another category. Say Onset (spoken: Onset ellipsis, or Onset dot. The reason for this is that only saying Onset will match with the first occurrence of the word, which in this case is Onset Mode. We want the second occurrence, so we dictate dot or ellipsis, and NoteSwift will now find Onset ) Say Week, 2, Next Category Noteswift selects the weeks (ago) finding, places the value 2 in it, and is ready to enter data into another category.

30 26 NoteSwift does not require you to dictate an entire term exactly as it is written. You can dictate part of a finding, and NoteSwift will look for the first closest match. For example, it would be difficult to accurately dictate week(s) ago. But, since week is a word that is unique to that finding, NoteSwift locates it correctly simply by dictating Week. With practice, you ll learn how to quickly get to the desired items, letting NoteSwift do the work for you. To enter findings for more categories, here are some things you can try: Preceding Event, An upper respiratory infection, Next Category Exacerbating Factors, Exercise, Note (to jump directly to the Note field) Patient states that the symptoms worsen with exertion. When dictating findings, you can also say All Positive, or All Negative. This will set all the findings to either positive or negative.

31 27 When you are done dictating for this complaint, you can say: Next to select another complaint Done to dismiss the NoteSwift Reason for Visit window Or, you can dictate the next section of the note you wish to work in, such as ROS Template.

32 28 History of Present Illness (Reason for Visit) Reason for Visit is the recommended best practice for entering structured data as required for Meaningful Use. However, the HPI exists entering unstructured data into the Reason for Visit Note. Call up the History of Present Illness window. Say HPI (or History or History of Present Illness) The History of Present Illness window appears. Dictate the patients history. For example: The patient comes in today with symptoms consistent with bronchitis. She complains of a cough and wheezing. Symptoms do not include shortness of breath or hemoptysis, her sputum is clear. Onset was 2 weeks ago, following an upper respiratory infection. Patient states that her symptoms worsen with exertion. The words you dictated will appear in the HPI window. If there was existing highlighted text already in the window, the new dictation will replace it. Say Done or the name of the next window, such as ROS Template. The text is transferred to the Note section of Allscripts Professional Reason for Visit.

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34 30 Other Commands Available in the HPI Window: Recover brings back the text from a prior HPI dictation. This is useful if the text was lost from a previous dictation. To recover lost text or text not transferred: Say HPI Say Recover Append moves the cursor to the end of existing text and adds additional dictation to the end of previous dictated notes. This is useful if you have already dictated the HPI and need to add additional information. From the HPI window click or say Append and continue with your dictation. Say HPI first to open the HPI window and then you continue as mentioned above. Then say Next or Done, or the name of another note section.

35 31 Creating an Alias Aliases allow you to substitute a simpler term for an existing system term or template name. For example, it is easier to say GERD than Gastroesophageal Reflux Disorder. Or COPD over Chronic Obstructive Pulmonary Disorder. Also, things such as template names may have any variety of punctuation according to your naming conventions, which may be difficult to dictate. You can create Aliases in a number of NoteSwift windows such as: ROS Template Exam Template Social History Medications Prescribe Plan The way in which Aliases for templates are created for ROS and Exam Templates are slightly different than for other forms. Both methods are described here. Creating aliases for ROS Template and Exam Template In this example, we will create an Alias in the ROS Template NoteSwift window. Say ROS Template The ROS Template window appears. Say Alias The Alias dialog appears. In the field titled Spoken Alias type or dictate the term you wish to use. (In this example, the spoken alias complete female will be defined for the Template Term General Multi-System Adult Female Complete ) You then select the desired template from the Templates pull-down list within Allscripts Pro. Say Done

36 32 1. Enter the spoken alias term 2. Select the desired template Creating an alias for Exam Templates works in the same manner. Creating aliases for other NoteSwift forms In this example, we will create an alias for the Plan form. Say: Plan - to bring up the plan form Labs - to set the target to the Labs source Alias to bring up the Alias dialog.

37 33 In this example we will create the alias CMP which will refer to METABOLIC PANEL, COMPREHENSIVE (90053). In the Spoken Alias field, type CMP. In the Search Term field, type in METABOLIC PANEL, COMPREHENSIVE (90053). In this alias form, you will also select the search source, in this case Labs. Say Done Now when you use the Plan Form you can dictate CMP, and NoteSwift will select the appropriate lab for you.

38 34 Documenting the Review of Systems The ROS window allows the provider to modify an existing ROS template. NoteSwift is good at recognizing varying terms for ROS text, but it expects a certain format. Generally templates are used to document negatives, but they can be used for positives as well. Using a Template in the ROS window: If you would like to use a pre existing template in the ROS window, call up your ROS template. Say ROS Template The ROS Template window opens showing ROS templates available. In the example below, we have a NoteSwift form populated with Template Terms that have corresponding Aliases. If you have not yet read the section on Aliases, do so now. Speak the name of the template you wish to apply. In this example we will use the alias that we created in the previous example on pages Say Complete Female This selects the General Multi System Adult Female Complete Exam. (See image below.)

39 35 When finished, say Done or the next area you wish to document, such as ROS. To apply the previous encounter as a template, say Last Visit.

40 36 Review of Systems Call up the ROS window. Say ROS (or Review of Systems) The NoteSwift ROS window appears. Say Cough, for two weeks. (Remember that the comma means to pause). Cough is entered in the Positive finding field, and the cursor auto-jumps to the Note where the text for 2 weeks is entered. Say Next If you wish to dictate a negative finding, say Negative and then dictate the finding into the negative field. You can switch back to documenting positive findings by saying Positive before dictating any additional findings.

41 37 Make sure that the toggle Navigation button is set to on, and the navigation window is displayed. Any note text that is dictated during the Review of Systems is added and appears beside the corresponding symptom. Present symptom notes appear in all caps. Not Present (negative) notes appear in proper case. Reminder - The ROS form by default starts with the cursor in the Finding field and the default is set to Positive. Speak the name of the finding when the cursor is in the Finding field. NoteSwift highlights that term and jumps to the Note section. You can then optionally dictate narrative text about that finding. Say Next, and the ROS is changed. When finished, dictate your next area of documentation, such as Past Medical History.

42 38 Past Medical History To dictate the Past Medical History into your encounter say Past Medical The Past Medical History window appears. Dictate the medical condition into the Item field. For this example, we will say Hypertension After you say hypertension and pause your voice, the cursor automatically jumps to the Note field. Dictate a note for the condition. To dictate additional conditions, say Next and continue adding conditions as mentioned above. When finished say Done, or the next area of documentation such as Social History.

43 39 Social History Say Social History The Social History window appears. Dictate the social history item Say Alcohol When you pause your voice, the cursor automatically jumps to the Note field. Dictate a note for the item. She admits to 2 glasses of wine per day with dinner. Say Next to add additional items. Try adding data such as Living Situation, Current Work Status or Tobacco History using the above method. Say Done or the next area of documentation such as Family History when finished adding items. The Source defaults to Social for the search and entry. If you wish, you can also say Free Text to dictate the finding as unstructured data. You will see the radio button change

44 40 Family History Say Family History The Family History window appears. Say Father The cursor will automatically jump to the Note field. Say Coronary artery disease Say Next if other family history items need to be added. The history item is transferred and you are ready to dictate another item. When all items are added say Done, or the next area of documentation such as Allergies. Pregnancy History and Travel History, although not covered in this manual, work in the same manner as Family History.

45 41 Allergies Say Allergies to open the Allergies window Dictate an allergen into the Item field. Say Penicillin The cursor automatically jumps to the Note section. Dictate the allergy reaction, for example, Anaphylaxis. Allscripts Professional EHR categorizes allergens into different types (Drug, Common, Drug Class). You can choose the allergen type for the particular item. When you select an allergy type for a particular item, NoteSwift remembers it the next time you dictate that item. Say Next to add another allergy. The information is transferred to the encounter in Allscripts Professional EHR. When finished, say the name of the next section you wish to move to such as Medication History, or say Done.

46 42 If the Allscripts Professional EHR search results in more than one result, NoteSwift defaults to the first item listed. If the first item in the list is not the one needed, single-click on the item you want in Allscripts Professional EHR and then say Next to transfer the data. Alternatively, you can say Item to position the cursor on the Item field, say Select all to select the previous entry, and then dictate a more exact version of the item you want to select, such as Penicillin G Procaine.

47 43 Medication History Call up the Medications History window. Say Medications. Dictate the medications your patient is taking. In these examples, dictate the medications all in one command speaking fluidly. NoteSwift will automatically parse all the data for you and put the drug name strength and dosage all in the right places. Say Lisinopril 20 mg daily (Pronounce mg as milligrams ) Next Low dose aspirin QD Next NoteSwift searches for the dictated medication and dosage when you pause your voice. If there are multiple medications matching your search, you can either single-click on the medication that you want, or, by dictating a more exact version of your choice. You can accomplish this by saying Clear to erase the NoteSwift field, and dictating your new selection. When you are finished, say Next to continue adding medications. Say Done when finished, or the next section you want to move to, such as Exam.

48 44 Medications are entered as structured data and as such can be used in the Assessment and Plan to prescribe the medications. Unknown Dosages: If you do not know the dosage of a medication, dictate unknown as the dosage. Medication Extras: Number: You can specify a range, such as Lortab 1-2 daily PRN (use the word hyphen for the dash, say one hyphen two for 1-2). Frequency: NoteSwift understands most standard medical abbreviations such as QD, BID, and TID. PRN: NoteSwift supports the term PRN or as needed at the end of the dictation, along with the reason. For example, Lasix 20mg 1-2 daily PRN edema. No Meds: If the patient is on no meds, activate the No Current Medications button in the Medications window by saying None.

49 45 Documenting the Physical Exam When your Exam Template window opens, you will see the list of Aliases for templates customized for use with NoteSwift. Creating your own Aliases will allow you to use a spoken term to apply either system-delivered templates or the customized NoteSwift templates. Open the Exam Template window. Say Exam Template Speak the spoken term of the Alias you have created. In this example, we will use general exam. If you have not yet read the section on Aliases (page 31), do so now. Say General Exam Say the next area of documentation such as Exam, or Done to apply the template. The template window applies the template. You are now ready to dictate the physical exam.

50 46 As with ROS Template, you can say Last Visit to bring in the previous encounter as the exam template. Physical Exam The physical exam window uses the search functionality within the Physical Exam to document positive and negative findings. Set-up and customization needs to have been completed by your NoteSwift implementation specialist for this to happen. If you have not had this done, you will need to document the physical exam using the point-and-click method. If customization has been completed follow the directions below: After completing the above steps to apply the physical exam template Say, Exam to open the Physical Exam window. To dictate a positive finding, make sure the cursor is in the Positive text box. You can switch between positive and negative finding by saying Positive to document the positive findings or Negative to document negative findings.

51 47 When you pause after dictating a finding, the cursor will jump to the Note box. You can then dictate a comment related to the finding. The note is added to the note section of the finding in the Allscripts Professional EHR Physical Exam. Say Lung Sounds, Wheezing noted bilaterally. (Remember the comma means to pause, so NoteSwift will auto-jump to the Note field).

52 48 Make sure that the Navigation toggle button is set to on The search pane to the left should look like this Abnormal findings are noted in all caps. Notes are added to the appropriate section. Say Next to continue adding information. When you are finished, say Done, or the name of the next section you wish to move to such Assessment to document the Assessment and Plan.

53 49 Assessment The Assessment window provides many options for entering structured data into the note. You can: Access information from My Short Lists, Short Lists, the Patient Problem List, or search the Master List Easily navigate to, and select one-click protocols Navigate protocols with folders, selecting diagnoses and plan items from virtually any folder structure. Navigate more complex structures containing nested folders. Say Assessment to open the Assessment window. The tab selected in the EHR will match whatever your system default is. In this example, we will work from My Short Lists. The Short List item Sick Visit has been created for this tutorial. It contains two different styles of protocols, as shown:

54 50 This is a folder-style protocol. The available medications, procedures, education and follow-up options are stored in separate folders. This is a one-click protocol. The medications, procedures, etc. are located with the diagnosis, and can all be entered in a single operation. We ll first look at the one-click protocol for Bronchitis. In the NoteSwift Assessment window, first open the Sick Visit folder. Say Sick Visit NoteSwift opens the folder. Whenever a folder also contains a folder named Protocols, NoteSwift will conveniently open that at the same time.

55 51 Say Bronchitis NoteSwift selects the one-click protocol. To add this protocol to the Current Plans, say Next Item, and continue entering additional items. Say Next or Done if you are finished with this assessment.

56 52 Now, we ll take a step back and document via a folder-style protocol. First, delete the prior assessment in the EHR to avoid any conflicts. Say Assessment to bring up the Assessment window, Say Sick Visit to open the Sick Visit Short List item, NoteSwift opens Sick Visit, and the Protocols: directory as it did in the first example. Say Cough and NoteSwift selects and highlights the Cough protocol. The cursor auto-jumps to the Note field. Dictate additional information, such as I will order today a chest x-ray to ensure there is no underlying pneumonia. I'll also give the patient a prescription for prednisone. I will see her back in our office in 1 week. Say Next Item to add the diagnosis and note text into the Current Plans.

57 53 You will see that in the process of entering the diagnosis into the Current Plans window, the Cough folder was opened so that additional items can be added by navigating the folders within. Say Open Medications (or Expand Medications) and the folder will open, revealing a list of medications. You can now dictate the desired items into the Item field, adding Note text if desired. For example, say Prednisone, Next Item And the prescription will be added with the diagnosis in the Current Plans.

58 54 Here is the Cough protocol with all of the folders opened, showing the items contained within:

59 55 You may want to create this or a similar Short List protocol for practice. To complete this assessment example, you can try the following. Say: Open Procedures Chest X-Ray Next Item CBC Next Item Open follow In 1 week Say Next if you want to go back to the top and close all the folders to start a new assessment, or Done if you are finished with the assessment. You can also say the name of another area, such as Plan.

60 56 More about navigation in Assessment Dictating the name of any of the radio buttons in the NoteSwift Assessment window will select that tab in the EHR. Selecting Search allows you to search for and select diagnoses in the master list. You can then add procedures and medications to the selected diagnosis following the assessment, via the NoteSwift Plan and Prescribe windows. This may be helpful when you need to add an additional assessment for which you don t currently have a Short List. By selecting Free Text, you can enter your assessment as unstructured data. Dictate the assessment in the Item field, and any narrative into the Note field. The information will be entered into the Current Plans as unstructured data.

61 57 You can also select Patient Problem List to bring in an assessment from a previous encounter. Again, you can use the Plan and Prescribe capabilities in NoteSwift to add medications, procedures, and the like to the diagnosis.

62 58 Plan The NoteSwift Plan window allows you to order individual items such as procedures, labs, referrals, etc. You can enter from various sources or you may specify Short List. To use a Short List, you must first enter the information for your Short List in NoteSwift. Setting Default Target for the Plan window From the main NoteSwift window, select Options. The Options dialog appears. Click on the Plan tab. Choose a default target. If you choose Short List, enter the name of the Short List you will use. Click Save

63 59 Say Plan (or Orders) to open the Plan window The target can be changed when you are in the Assessment and Plan by dictating the name of the target (e.g. Labs) you wish to search. Select the diagnosis for which you will be adding new orders if it is not already selected in the Current Plans window of the EHR. Dictate the order which you want to add. If there are multiple in the list, single-click on the item that you are ordering and say Next. To add a new order to the Cough diagnosis, first make sure it is highlighted in the Current Plans window. Say CT Sinus Select the desired choice from the search results by single-clicking, then say Next to add the procedure to the Current Plans for Cough.

64 60 Continue this process until you have added all orders. When you are finished say Done, or the next area of documentation such as Prescribe.

65 61 Prescribe To order a new medication for a patient, say Prescribe (or New Prescription) to open the Prescribe window. Dictate the medication name, strength, dosage, number and refills. To dictate the example above you would say Prednisone 10 milligrams daily count 30 refills 3

66 62 NoteSwift searches for the medication and dosage and delivers the search result. If you do not singleclick an entry, the first entry in the search result will be applied by default. If the desired drug/dosage dictated does not appear first on the list, click once to select the drug and dosage you need. Say Next to continue adding medications, or when finished say Done. Before continuing, you will be required to Click OK to close the EHR prescription window. This is one of the few places where you are required to manually click, to allow you to review the prescription prior to submitting it. At this point if you say Next, The NoteSwift window will still be displayed and will be waiting for you to dismiss the prescription window in order to dictate the next prescription.

67 63 Dictation As a convenience, NoteSwift offers a dictation box, which allows you to quickly dictate free text to be pasted into whichever area you choose, without having to leave NoteSwift. First, place the cursor where you would like to insert text. Say Dictation to open the NoteSwift dictation window. You are now free to dictate your information. You can also say or press Recover to bring back text from a prior dictation. When you are finished dictating say Done, and the text will be inserted into the selected field.

68 64 If you have finished entering all desired sections of your note, click on the History and Physical icon in Allscripts Professional EHR to see what your complete patient encounter looks like: Amy NoteSwift 9/26/rrrrrrr 10:50 AM Location: Professional Main Location Patient #: 1234Swift DOB: 5/20/1978 Married / Language: Undefined / Race: Undefined Female History of Present Illness (Terry A Manning, MD; 9/26/ :27 PM) The patient is a 36 year old female who presents with chronic bronchitis. Symptoms include cough (Started 2 weeks ago after a cold.) and wheezing (Worsens with exertion. She is using her MDI as needed.), while symptoms do not include hemoptysis (Sputum is clear area) or shortness of breath. Onset was 2 week(s) ago. Onset followed an upper respiratory infection. Symptoms are exacerbated by exercise (Patient states that the symptoms worsen with exertion.). Problem List/Past Medical (Terry A Manning, MD; 9/28/2014 9:06 AM) Hypertension (401.9) Allergies (Terry A Manning, MD; 9/26/2014 3:15 PM) Penicillin G Benzathine & Proc *PENICILLINS*. Anaphylaxis Medication History (Terry A Manning, MD; 9/26/2014 3:44 PM) Lisinopril (20MG Tablet, Oral daily) Active. Low-Dose Aspirin (81MG Tablet, Oral daily) Active. Social History (Terry A Manning, MD; 9/26/2014 2:41 PM) Alcohol use. She admits to 2 glasses of wine per day with dinner. Current work status Family History (Terry A Manning, MD; 9/26/2014 2:43 PM) Father. Coronary artery disease Review of Systems (Terry A Manning, MD; 9/26/2014 2:15 PM) General: Present- Feeling well. Not Present- Fatigue, Fever, Night Sweats, Weight Gain > 10lbs. and Weight Loss > 10lbs.. Skin: Not Present- Change in Wart/Mole, Itching, New Lesions and Rash. HEENT: Not Present- Headache, Visual Disturbances, Hearing Loss, Frequent Colds, Bleeding Gums and Hoarseness. Neck: Not Present- Swollen Glands. Respiratory: Present- Cough (FOR 2 WEEKS.). Not Present- Difficulty Breathing. Breast: Not Present- Breast Mass, Breast Pain, Nipple Discharge and Skin Changes. Cardiovascular: Not Present- Chest Pain, Shortness of Breath and Swelling of Extremities. Gastrointestinal: Not Present- Abdominal Pain, Constipation, Diarrhea, Difficulty Swallowing and Rectal Bleeding. Female Genitourinary: Not Present- Frequency, Menstrual Irregularities, Painful Urination, Pelvic Pain, Urgency and Vaginal Discharge. Musculoskeletal: Not Present- Calf Pain, Joint Pain and Muscle Cramps. Neurological: Not Present- Dizziness, Numbness and Weakness. Psychiatric: Not Present- Anxiety, Change in Sleep Pattern and Mood changes. Endocrine: Not Present- Cold Intolerance, Excessive Thirst, Excessive Urination and Heat Intolerance. Hematology: Not Present- Easy Bruising, Enlarged Lymph Nodes and Prolonged Bleeding. Physical Exam (Terry A Manning, MD; 9/26/2014 4:12 PM) The physical exam findings are as follows: General Constitutional - Normal appearance. Integumentary Skin - Normal skin, Normal skin appearance and Incision clean, dry, intact consistent with normal anticipated wound healing. No skin nodules. Head and Neck Neck - Normal jugular pulses, Normal thyroid size and consistency without masses and Trachea midline. Eye Eyes - Normal lids and conjunctiva, Normal pupils and irises and Normal fundi. ENMT ENT - Normal external ears and nose, Normal ear canals and tympanic membranes, Normal hearing, Normal nasal mucosa, Normal mouth and Normal oropharynx. Chest and Lung Exam Chest - ABNORMAL LUNG SOUNDS (WHEEZING NOTED BILATERALLY.). Normal respiratory effort, Normal chest percussion and Normal chest palpation. Cardiovascular Cardiovascular - Normal heart sounds, Normal carotids, Normal abdominal aorta, Normal femoral pulses and Normal foot pulses. No leg edema. Neurologic Neuro - Normal cranial nerves, Normal strength and tone, Normal reflexes and Normal sensation. Neuropsychiatric Psych - Normal mood and affect and Normal mental status. Musculoskeletal Musculoskeletal - Normal gait, Normal digits, Normal extremities and Normal spine. Lymphatic Lymph - No neck lymphadenopathy, axillary lymphadenopathy or inguinal lymphadenopathy. Assessment & Plan (Terry A Manning, MD; 9/28/2014 9:42 AM) Cough (786.2) Current Plans CHEST X-RAY, PA AND LATERAL (71020) CBC & PLATELETS (AUTO) (85027) Follow up in 1 week or as needed CT SINUS WO/W CON (70488) Started PredniSONE 10MG, 1 (one) Tablet daily, #30, 09/28/2014, Ref. x3.

69 65 NoteSwift Menus and Options Options... Users Help Customization options for each NoteSwift form. Tools for creating, selecting and editing user profiles, as well as importing and exporting information from other profiles Provides links to documentation, as well as version and support information. Options There is a tab for a number of NoteSwift forms, as well as the General and Unity tabs. Each tab contains several options to change the behavior for the corresponding form. With the exception of the Plan and PMH tabs, you should not need to change any options from their default setting.

70 66 General Next/Done Hotkey Auto Jump to Note Allows you to create a keyboard hotkey which you can use instead of dictating Next. This causes NoteSwift to automatically move the cursor to the Note area after dictating fields. Transfer Note Using This should not be changed from the default Clipboard unless instructed to do so by support staff.

71 67 Unity This is where the Allscripts Unity Service URL, and the User Name and Password are entered. This is reserved for future use. HPI

72 68 Transfer Text Using Delete Old HPI When Transferring Text This should not be changed from the default Clipboard unless instructed to do so by support staff. This default will remove any existing Note text in Reason for Visit prior to transferring the current text. ROS All Caps Abnormal Findings This default converts Review of Systems abnormal finding text to all caps.

73 69 PMH (Past Medical History) Target Free Text/Search determines where NoteSwift will enter PMH data. Exam

74 70 All Caps Abnormal Findings This default converts the note text associated with a positive finding to all caps. Plan Default Target Default Short List This selection defines which data source will be searched by default for plan items If Short List is selected, the specified folder in the Default Short List field will be automatically opened when navigating to plan

75 71 History Social history defaults to Free Text When checked, NoteSwift will enter any social history items dictated as free text, rather than searching for the item within the social history source

76 72 Dictation Transfer Text Using This should not be changed from the default Clipboard unless instructed to do so by support staff Users Importing / Exporting Aliases NoteSwift provides the ability to import and export your aliases. You can import either from another user profile you have created in your NoteSwift environment, or a folder. You can export your aliases to a folder. In the NoteSwift application, select Users->Export->To Folder

77 73 From here, you will browse to the folder where you d like to place your alias files, optionally creating a new folder for them. To import from another user, select Users->Import->From User Here you can select another user profile and the Aliases you wish to import from it into your currently active profile. To import from a folder, select Users->Import->From Folder

78 74 Select the alias files you wish to import, browse to the directory where they are located, and click Import. Help The following table outlines the help menu items User Manual Release Notes About Server Log Clear Cache Links to the latest online version of this manual Links to the latest online version of the product release notes Displays a splash screen with pertinent version and license information regarding NoteSwift Saves the current NoteSwift activity to a file for use by support and development. Do this only if instructed to by support staff NoteSwift caches some information to help improve navigation speed. Support may ask you to select this option if you begin experiencing certain behaviors when using NoteSwift

79 75 Appendix A: Command Cheat Sheet This is the list of available commands used to call up the NoteSwift windows, and commands available within each window. In addition to what is listed in the table, you can always dictate Done, Next and Cancel. You can also say the name of any field within a NoteSwift window to move the cursor there. NoteSwift Window What to say to call up the NoteSwift Window What else you can say Allergies Allergies Drug, Common, Drug Class, No Allergies Assessment Assessment Open <item/folder>, Expand <item/folder>, Open Item, Next Item, My Short Lists, Short Lists, Search, Free Text, Patient Problem List Diagnostic Studies Diagnostic Studies Dictation Dictation Recover Exam Template Exam Template Alias, Last Visit Family History Family History Health Maintenance Health Maintenance History of Present Illness HPI, History, History of Present Illness Append, Recover Medications Medications, Meds, Problem List Alias, Clear N/A No Meds, Meds Review N/A Dictation Past Medical History Past Medical, Past Medical History Free Text, Search, Alias Past Surgical History Past Surgical, Past Surgical History Physical Exam Exam Alias, Positive, Negative Plan Plan, Orders Alias, Short List, Procedure, Labs, Education, Office, Discharge Plan, Nursing, Forms, Referral Pregnancy History Pregnancy History Prescribe Prescribe, New Prescription Alias, Clear Reason for Visit Reason for Visit Search For <item>, Lookup <item> Clear Search, Open <item/folder>, Choose <item/folder>, Next Category, Next Finding, Previous Complaints, My Short Lists, Short Lists, Master List, All Positive, All Negative Review of Systems ROS, Review of Systems Positive, Negative, Alias ROS Template ROS Template Alias, Last Visit, Last Office Visit Social History Social History Free Text, Social Travel History Travel History