Ambulatory PowerNotes® & Ambulatory Dynamic Documentation® Presented by the IS Training Staff, Children’s Hospital of The King’s Daughters April 2015

How to Use this Tutorial Welcome to the Introduction to Physician Documentation tutorial for Ambulatory Providers. This tutorial will give you general information on how to create and use PowerNotes® as well as Dynamic Documentation®

Navigation There are several ways to navigate through the content of this tutorial. A few methods include: Click your left mouse button or use the page down key on your keyboard to move forward in this slide presentation. Right-click on the current slide and choose ‘Reverse’ to go back to a previous slide in the presentation. 3

Course Objectives Purpose: The purpose of this tutorial is to provide you with a high level overview of the key features of PowerNotes. In this brief lesson you will learn how to: Create and Use PowerNotes Create and Use Macros Create and Use Auto-Text Create and Use Precompleted Notes

Strategies for Success Remember, before you will be allowed to access eKiDs PowerChart, you must: Successfully pass the eKiDs Ambulatory PowerChart Basics proficiency test with 80% or higher. Complete all applicable PowerChart training as indicated by your manager or education coordinator. Sign the Information Services’ Systems Access and Confidentiality Acknowledgement.

Accessing PowerChart – Complications??? If there are any problems accessing PowerChart or if you do not know your login credentials, contact the IS Help Desk at 668-7075. If you have problems within the application call the IS support line at 668-5470

To go to Lesson Two, click the eKiDs icon below. End of Lesson One To go to Lesson Two, click the eKiDs icon below.

Lesson Two: Creating PowerNotes In this lesson you will learn: How to Create PowerNotes

Sample Workflow Patient Johnny Q has presented for a four year Well Child Check. The nurse has completed the Ambulatory Intake, documenting the Height, Weight, reason(s) for visit, etc. The patient has also been roomed. Prior to entering the room, you have reviewed the Ambulatory Summary (which contains information that the nurse has entered for the visit). You are now ready to initiate a PowerNote for the patient.

Ambulatory Quick Note Prior to entering the room, you have reviewed the Ambulatory Quick Note (which contains information that the nurse has entered for the visit). Information may also be reviewed on the Ambulatory Summary.

Ambulatory Summary From the Ambulatory Summary, select the ‘+’ sign beside the Documents tab to add a PowerNote.

The date will default. Select the Note type from the Catalog to begin creating a note. Expand the folders by clicking the ‘+’ sign.

The Auto-Populate window opens every time that you create a PowerNote. By default, all items will be pre-selected in the Auto-Populate window to be included in the PowerNote. You can de-select the items that you do not want to appear on the PowerNote by un-checking the box next to the entry.

The selected PowerNote will appear with Auto Populate terms already entered. The note is defaulted to hide the structure of all paragraphs within the note, with the exception of the Chief Complaint paragraph.

Documentation Options You can expand and collapse paragraphs in PowerNotes using <Show Structure> and <Hide Structure>. These options put a focus on the information that you want displayed. Above, <Show Structure> has been selected, displaying the structure of a paragraph including the sentences and terms.

Documentation Options <Hide Structure> collapses the paragraph hiding the sentences and terms. Above, <Hide Structure> has been selected for the data above to collapse the Well Child History section. The Review of Systems section has been expanded by using <Show Structure>.

Documentation Options Negating a Term The first time that you click on a term in the PowerNote, it will be selected to be included in the PowerNote. The second time that you click on the term, it will be negated and a strike-through will appear. The third time that you click on the same term, the entry will be cleared.

Documentation Options Using the OTHER term The “OTHER” term is an option available for inserting freetext into a note. It is recommended to use the “OTHER” term when documenting brief and term specific information within a note. This term is generally the last term available for every sentence within a paragraph.

Documentation Options Using the Freetext Option Freetext allows you to enter text directly into a PowerNote without selecting any terms or sentences from the template provided. Double clicking within any portion of the note allows text to be inserted directly into the note. To enable free text at the beginning of a note, double click in a white area between the between the note header and the first paragraph. A cursor will appear to allow free-texting to begin.

Documentation Options Adding Orders from within PowerNotes To add an Order from within a PowerNote, complete the following steps: Select PowerOrders under DX and Plan. The screen will change to the Add window, where you can add orders, medications, etc. (For additional information on entering orders, see the Order Entry section). The order will appear under PowerOrders in the Diagnosis and Plan section.

You are able to use the undo option to clear out the last unsaved change that you made to the system. You can select undo from the Edit Menu while on the current PowerNote.

Signing and Submitting Signing and Submitting PowerNotes If you would like to save it for future editing (because you have not completed it yet), select Save. Then click OK. To Save the Note and close the PowerNote form, click Save and Close. Then click OK. To cancel the note completely, click Cancel.

New PowerNote Features The default font can be used on results displayed in a PowerNote document. The system now tracks when you select Copy Forward or copy and paste structured data from one note to another. The system now tracks when you delete Precompleted notes and macros and a warning message is displayed if shared or Precompleted notes are deleted.

To go to Lesson Three, click the eKiDs icon below. End of Lesson Two To go to Lesson Three, click the eKiDs icon below.

Lesson Three: Creating and Using Macros In this lesson you will learn: How to Create and Use Macros

Sample Workflow Macros are partially completed personal templates that you use frequently. They can be comprised of terms, sentences or a paragraph. Using Macros will simplify how you enter / create your PowerNotes. You would use a Macro to complete a specific section that is common (ex. documenting Enlarged, Firm, and Mobile Glands in the Physical Examination section for a Strep Patient).

To begin entering a Macro, create a PowerNote and document the terms to be included in the macro. Once all of the terms have been selected, right click on the note and select “Save Macro As.”

Within the Title field, enter the name of the macro. Selecting “Create as shared” will make the macro available to all users (with access to PowerNotes) within the organization. When this checkbox is left blank, only you will see the macro. Select “Create New” to save the macro.

An M beside the paragraph (in this case, Review of Systems) indicates that a macro has been built and is ready for use.

Using Macros Once your macros have been built, you are able to insert them into a PowerNote. To insert the macro, click on the blue “M” indicator. A dialog box will appear that will display the names of all available macros on the top half. The bottom half of the dialog will display the option for “more…”

Using Macros Click on the name of the macro to insert it into the note. The options that were selected from the macro that you built will appear in the PowerNote. Selecting “more…” from the dialog box will display all personal and available shared macros for that indicator.

To go to Lesson Four, click the eKiDs icon below. End of Lesson Three To go to Lesson Four, click the eKiDs icon below.

Lesson Four: Creating and Using Auto-Text In this lesson you will learn: How to Create and Use Auto-Text

Sample Workflow You can create auto-text for entries that you often type into a PowerNote. By using a standard naming convention, you can easily select auto-text that you created and add it into your PowerNote. For example, Dr. Huxtable commonly types in “Avoid migraine triggers such as caffeine, lack of sleep, poor eating….” to his Migraine PowerNotes. Instead of typing the text for every applicable visit, he can type it once, save it as an autotext, and apply it to PowerNotes as needed.

To begin adding auto-text, select an Other box and enter the appropriate information.

Using Auto-Text

Using Auto Text Highlight the text. Then right-click and select Save as Auto Text.

Using Auto Text In the Manage Auto Text window, enter the abbreviation and the description of the autotext. (Note, it may be helpful to begin your auto text with a character that you do not use often such as ‘%’.) When finished, click Save. Click close to close the window.

Using Auto Text When you are ready to use the auto text that you created, simply begin typing the text abbreviation into an other box. The auto text abbreviation will appear. Double click on it and the auto text will be added into your PowerNote.

To go to Lesson Five, click the eKiDs icon below. End of Lesson Four To go to Lesson Five, click the eKiDs icon below.

Lesson Five: Creating and Using Pre-Completed Notes In this lesson you will learn: How to Create and Use Pre-Completed Notes

Sample Workflow Precompleted Notes allows you to save a note that you intend to use often so that it can be partially completed for you later. You can reuse your precompleted note as often as you would like. Dr. Hawkeye Pierce sees a fairly high number of strep patients. He created a PowerNote once, documenting information that occurs in the majority of the cases (i.e. swollen glands, sore throat, fever) and saves the note. Dr. Pierce can later use the same note on other patients and make changes to the note based on the visit that he is seeing.

To create a Precompleted Note, open a new PowerNote To create a Precompleted Note, open a new PowerNote. Then document the encounter information, selecting the recurring data elements and excluding patient/encounter specific data.

Once the note has been documented, from the Documentation menu, select “Save As Precompleted Note.” This will launch the “Save As Precompleted Note” dialog box.

In the Note Title box, enter a title for the Precompleted Note In the Note Title box, enter a title for the Precompleted Note. Select “Save as New” to save the note. The Precompleted Note is now a user specific note that can only be used and updated you. Note: Additional options such as sharing and updating precompleted notes are discussed and demonstrated during classroom instruction.

To apply a note that you have created to a patient, select the Precompleted Tab within PowerNotes. Then locate the note that you want to use and select OK.

The note will be created with the data elements that you already selected.

Tips and Tricks If you saved a precompleted note in error, you can delete it. Remember that if you use someone else’s precompleted note, save it as your own before making any changes. Macros are typically not shared. Autotext can be modified, as necessary (additional information on modifying auto-text is provided during training classes) Remember: The system now tracks when you delete Precompleted notes and macros and a warning message is displayed if shared or Precompleted notes are deleted.

End of PowerNote Proceed to the Dynamic Documentation Lesson by clicking the eKiDs icon below.

Dynamic Documentation In this lesson you will learn: How to use Dynamic Documentation

Dynamic Doc Overview Dynamic Documentation is an alternative to PowerNote It efficiently pulls data from a patient’s chart, and allows providers to create free text entries for flexible and efficient clinical documentation Providers can utilize dictation, via Dragon®, to create their documentation Providers can utilize Auto Text to quickly enter free text used often

Dynamic Doc Creation Within the Physician Documentation chart tab, click the downward arrow next to the Add button Select Dynamic Documentation

Dynamic Doc Creation Select a note type from the Type field Select a type list from the Note Type List field Enter a title for the note Define the service date and time Choose a reference template from the bottom of the page

Removing Note Sections or Subsections Each section and subsection contains a bent arrow and an X icon located to the right of the section or subsection title, that are only visible when you hover the pointer over the section or subsection Complete the following steps to remove a note section or subsection

Removing Note Sections or Subsections Position the pointer over the section or subsection to be removed Select the X icon on the section or subsection Select the Undo button to revert your changes Section Subsection

Saving Documentation If you are not ready to submit and sign a note, and want to complete the documentation at a later time, you should save the note Saving enables you to make revisions to the note at a later time One should periodically save a note to preserve work in the event of a power outage or network failure

Saving Documentation Complete the following steps to save a note: From the toolbar or at the bottom of the note, click the Save button To save and close your work, click the Save & Close button

Saving Documentation If the note has been saved previously, changes are saved with an ‘In Progress’ status If the note has not been saved previously, the Save Note dialog box opens and the following can be updated: Note Type Title Date and Time Click OK, the note is saved with an ‘In Progress’ status

Signing Documentation When you are finished documenting the encounter, signing the note completes the documentation process, and publishes the note in the patient’s chart

Signing Documentation With the note open, click Sign/Submit From the Sign/Submit dialog box, you are able to edit the following: Title Date and Time Click Sign, the note now appears in the List tab of the document viewing window

End of Tutorial To access the Intro to PowerNote Competency, please click the link below.