Physician Documentation in the Electronic Medical Record

Users' Guide

Contents

Back to PICU Home Page

Introduction

There are at least two ways for physicians to enter a note into the Eclipsys Continuum 2000 electronic medical record, Progress Notes and Assessment Notes. There are advantages and disadvantages of each method. (See summary table for more details.) Progress notes are much like a blank page, without formatting or structure except for whatever is typed. Assessments have a structure with rows of parameters and time columns. The latter form allows users to maintain a structure to their notes from note to note. It also allows the text of an earlier note to be copy forwarded to a new time column.

Suggested usage: Assessment Notes are best suited for notes with a structure that is repeated daily. They should be used by the primary service to write daily progress notes on somewhat complicated patients who are likely to stay in the hospital for more than a couple of days. They should not be used by consulting services. Progress Notes should be used for short notes and/or unstructured notes such as procedure notes, consultant notes or addenda. They are also better suited for admission history and physicals. They may be inconvenient if used by the primary service for daily progress notes, but may be satisfactory if the notes are brief and non-repetitive.

These notes are also designed with the requirements of the Health Care Finance Administration's regulations (IL-273) in mind.

Prerequisites

Passwords

You must have a valid Eclipsys username and password before you begin. If you do not have one, please contact the Nurse Manager or Assistant Nurse Manager on your unit. Lending, borrowing or stealing someone else's password violates the rules and regulations of the Hospital and is subject to disciplinary action. You should aways log off before leaving a workstation. A quick way to log off is to hit the Esc key.

The generic password that allows you to view data does not allow you to enter data, including notes.

Screen Layout

Acquaint yourself with the various rows of buttons: Sections and Forms near the top of the screen, and Functions along the bottom. Section buttons are constant; whereas the forms buttons change whenever a different Section is selected. The function buttons change with the context of the task at hand. Functions can be invoked in any of 3 ways:

1. use the mouse and click on the function button on the screen with the left mouse button;
2. strike the key on the keyboard that corresponds to the function button on the screen; or
3. click and hold the right mouse button to get a menu to pop up on your screen, then use the mouse to choose the function, releasing the button to select it.

Look for the Message Box, a short but wide white rectangle just above the function buttons. Look in this area for messages from the system, particularly if a mouse click causes a gong to sound.

Also note the Login, Logout, Census, Patient, and Utility buttons along the very top of the screen. Their functions are somewhat self-explanatory. There is a blue Visit button that becomes active within a patient chart. This button allows you to view the patient's records of prior hospitalizations.

Navigation

You should also be aware of navigation tools that allow you to scroll up or down on a form or back and forth through time.

If a vertical scroll bar appears on the right of a form, there is more data to be viewed on that form. Many forms have scroll labels that appear when the the left mouse button is pressed when the mouse cursor overlies the scroll bar. These labels help you navigate to the desired parts of very long forms. The Page Up and Page Down buttons on your keyboard (Page Up or 9; and Page Down or 3 on your numeric keypad at the far right of the keyboard, not the 6-key pad with the Insert, Delete, Home, End, Page Up, and Page Down keys) can also help you navigate up and down a form. Be sure that the Num[ber] Lock light on your keyboard is off. If it is on, tap the Num Lock key on your keyboard until it goes off. Vertical scroll bars can also appear within a cell if there is more data in a cell than can be viewed in the space available.

If a horizontal scroll bar appears on the bottom of a form, the form can be navigated back and forth through time. The Newer (Home or 7) and Older (End or 1) buttons on your numeric keypad can also help you navigate through time. Be sure that the Num Lock light on your keyboard is off.

Text Editor/Word Processor

The word-processing functions have been upgraded, tremendously improving usability. Accessing these features are similar but not identical to common word processors such as Microsoft Word. Some of the differences can cause you to lose your work, so please be careful.

• The 6 keys just to the right of the Enter key and usually labeled Insert, Delete, Home, End, Page Up, and Page Down are "mapped" to entirely different functions: Ok, Sign, More, Command, Cancel, and Census. While this mapping appears to vary with context, I would not use these keys. Of particular concern it the Page Up key mapped to Cancel. Hitting this key will erase all of your unsigned work.

Insert OK	Home More	Page Up Cancel
Delete Sign	End Command	Page Down Census

• Use the Backspace key to delete text. The Shift-Backspace combination deletes the character to the right of the cursor (Progress Notes only, not in Assessment Notes). The Delete key does not act the way you would expect other Windows applications to act. See above.
• Selecting Text
  • Using the mouse, click and hold while dragging across the desired text.
  • Double-click to select a word.
  • Triple-click to select a paragraph.
  • Shift-left and right arrow keys select one character at a time.
  • Shift-up and down arrow keys select one line at a time.
  • Shift-End* selects to the end of the line.
  • Shift-Home* selects to the beginning of the line.
    * Not consistently mapped on every workstation.
• There are two cursors that can appear on the screen: the mouse cursor (a black arrow pointing up and to the left) and the caret. The former is obvious. The latter may be more difficult to spot. It is the small, up-pointing, black triangle that indicates the insertion point within a field or block of text. If the user begins to type or clicks on a list selection, text gets inserted at the caret.
• Cursor Navigation
  • Ctrl-left or right arrow moves the cursor one word to the left or right.
  • Ctrl-up or down arrow moves the cursor up or down one paragraph. (Ctrl-up arrow sometimes gets stuck at the top of the current paragraph and goes no further.)
• The "active window" is indicated by a green border. To make a window active, place the mouse cursor in that window. The arrow keys have different actions depending on which window is active!
• Portions of an unsigned note can be selected then cut, copied or pasted using the standard Windows key combinations for these functions. Entire notes or cells, once signed for, can be copied using the "Copy Note" function.
  • Ctrl-X or Shift-Delete* for cut
  • Ctrl-C or Ctrl-Insert* for copy
  • Ctrl-V or Shift-Insert* for paste
    * Not consistently mapped on every workstation.
• Copying Signed Notes
  • These word-processing functions work only on unsigned data. To copy signed notes, click on the note so that it is highlighted. Activate the function F3:Copy Note in one of the following 3 ways.
    1. Click on F3:Copy Note button at the very bottom of the screen; or
    2. Tap the F3 key at the top of your keyboard; or
    3. Click and hold the right mouse button until a menu appears, move the mouse over Copy Note, and let go of the button.
  • Once you have copied the note, you can paste it anywhere using Ctrl-V as above.
  • Note that some notes are not selectable and a message to that effect appears in the message box in the lower, left corner. These notes are Assessment Notes that have been "transformed" into the format of a Progress Note for viewing only. To select and copy these notes you must use the MD Assess form. On that form, you can only select and copy one cell at a time.
• Cut, Copy, and Paste also works between Eclipsys and other Windows applications. It is therefore at least theoretically possible to dictate into a Windows application, then copy the text into the "memory buffer" using Ctrl-C and subsequently paste it into a note in Eclipsys with Ctrl-V. (The caution is that selecting anything in Eclipsys will cause it to replace everything in this buffer, making it difficult to replace a block of text with the buffered text. Windows applications do not behave this way.)

Reading Notes

Review All

Notes are usually read in the order in which they are written. To be sure that you see all the notes, read them on the Review All form in the Notes section. This form is multidisciplinary and includes all physician, nursing, and ancillary notes. This form is review only, meaning none of the notes can be altered from this form. See Navigation for more information on moving about this form.

Directory

Look in the Directory that lists notes by their subtopic (for Progress Notes) or parameter (for Assessment Notes). To view a note:

1. Click on the title until it is highlighted.
2. Activate the function F2:Show Detail.

A small red "c" is visible at the far right of a directory entry indicates a corrected note. To view the correction history

1. Click on the title until it is highlighted.
2. Activate the function F2:Show Detail.
3. Click on the Older Value button.
4. Click on OK to close.

To cull the directory for a specific kind of note:

1. Activate the function F8:Select Notes.
2. Select notes by Topic/Subtopic (or Category/Parameter).
3. Click on the title of the note you wish to view until it is highlighted.
4. Activate the function F2:Show Detail.

Some notes (specifically the ones entitled "Assessment" or "Shift Assessment") are not viewable, these are the Assessment Notes that require the tabular format; however, all of these notes are "transformed" into the Progress Note format that can be viewed. Therefore, a message "Must use form where assessment was entered for any further action" in the Message Box should not discourage you; just look for the "transformed" note that can be identified by the identical time stamp and the red "Assessment" label in the right column.

If you try to leave this form but are unable to, look in the Message Box. If the message is "Cannot leave form with unsigned data," hit the Cancel button. A window pops up with the message "Press Cancel to lose unsigned data, OK to keep." Click on the Cancel button in this box. You should be able to leave this form now.

MD Progress

MD Progress Notes cannot be viewed from the MD Assess form (except if a Show Related Data form is configured to MD Progress), but Assessment Notes can be viewed from the MD Progress form because of a "transform" that converts those tabular notes into a block of text. This enables physicians to read all physician notes together without resorting to the Review All form.

If more than one user has signed for data in the same column on the MD Assess form, each section of the transformed note is prefaced with an author's label.

Progress Notes

Entering a Note

1. Open a chart.
   1. Click on the Census button at the very top of the screen. Then Click on the chart you want to open until it is highlighted. Activate the function F1:Open Chart in one of the following 3 ways.
      1. Click on F1:Open Chart button at the very bottom of the screen; or
      2. Tap the F1 key at the top of your keyboard; or
      3. Click and hold the right mouse button until a menu appears, move the mouse over Open Chart, and let go of the button.
   2. Alternatively, you can bypass the Census form by clicking on the Patient button at the very top of the screen; select the chart you want to open from the list presented by clicking on it. Click on Ok.
2. Select section Notes.
3. Select form MD Progress.
4. Activate the function F5:Enter Note.
5. A Enter Note window appears. Hit the Enter key twice if the time and date are okay.

   Either the time or date entry can be changed if desired. Note that this date and time are for purposes of labeling and positioning the note in the chart. The date and time that the note is actually signed, as well as a full revision history (from electronic signature to signature) are stored separately and are viewable with the Show Detail function.

6. Select a Topic with the mouse (directly under the time or date) or right-arrow key. Try "MD Notes Pediatric".
7. Select a Subtopic, such as "Pediatric Resident Note". If no appropriate subtopic currently exists in the system, you can create one for this chart only by typing in an entry. This entry will be available the next time you write a note. For a more permanent solution, contact the coordinator. (See Feedback.)
8. Click the left mouse button in the Text area below Associated Dx.
9. Note the caret or small black triangle where you clicked. This is the insertion point for any text you type or insert with the pop-up list.
10. Start typing a sentence, like "Interval history reviewed and patient examined with the attending on rounds."
11. Use the mouse. Click and hold down the left mouse button in the text, just to the left of "on rounds."
12. Drag the mouse to highlight "on rounds."
13. Hit the backspace key to delete the highlighted text.
14. Highlight another section of text such as "the attending."
15. Type a word or words such as "Dr. Doolittle". Note that the text you had highlighted is now replaced with the words you had just typed.

Entering Prewritten Text

1. Click the left mouse button in the Text area just below Associated Dx.
2. If a list of prewritten text entries has been created for this subtopic, it will appear in a pop-up window. Examine this list.
3. Note some items on the list are boldfaced. These are headers. Click the left mouse button on one of the headers. Items in the sublisting below the header collapse and an arrow appears to the left of the header. To expand the sublist, click on the header again. Alternatively, move the mouse cursor so that it lies in this window. Note the window's border becomes green, indicating that this window is "active." Now hit the right- or left-arrow key and note the effect.
4. Click the left mouse button on a non-boldfaced list item to insert a phrase or sentence. Alternatively, use the arrow keys while this window is active and note the effect of each the up-arrow, down-arrow, left-arrow, and right-arrow keys.
5. You can cull or pick out items from the list by typing a few characters. Try slowly typing the first few letters of a common word and watch the effect on the list. To reset the list, hit the space bar. (If this does not reset the list, move the caret to the bottom of the note and hit the space bar again.)
6. Some lists contain transforms that pull data from other parts of the chart, convert it into text strings, and inserts the data into your note. The existing transforms include:
   • VS Recent
   • CBC Recent
   • Differential Recent
   • Coags Recent
   • Chemistries Recent
   • ABG Recent
7. If any window is in your way, just click and hold the left mouse button on the window label at the top and move it out of your way. To make a pop-up list disappear altogether, just click on any of the "unselectable" blue areas on your screen.

Signing a Note

You must then sign it with your electronic signature in order to save it.

1. Once you have finished editing your note, click on the OK at the bottom of the Enter Note window.
2. Activate the function Sign at the bottom of the window, and another small window will appear.
3. Enter your password and click on OK in the little pop-up window (or hit the Enter key).

If you want to undo all of your work since your last signing for data, activate the function Cancel. A small window pops up stating "Press Cancel to lose unsigned data, OK to keep." If you wish to erase all of your work since your last signing, click on the Cancel button.

If you want to save your note to be completed later, click on the "yes" near the bottom of the window next to the words "Note Complete:" Wait for the "yes" to become "no." (This may take a few seconds, so be patient.) Click on the OK button. Note the "incomplete" at the top, right corner of the note. Now, signing this data will save your note, but will not make it a permanent part of the electronic medical record until the note is "completed" and signed. See the next section, Editing Text Already Signed to "complete" a note.

Editing Text Already Signed

1. Once data in a cell has been signed, clicking on that note causes it to be highlighted.

   Note that some notes are not selectable, these are Assessment Notes that have been "transformed" into the format of a Progress Note for viewing only. Editing these notes must be done in the MD Assess form.

2. To change what has been entered, activate the function F3:Correct Data. Make corrections to the note.
3. If the note were "Incomplete" and you now want to "Complete" it, simply click on the "no" next to the word "Note Complete:" Wait for the "no" to become "yes." (This may take a few seconds, so be patient.)
4. Click on the OK button at the bottom of the window.
5. Sign the note.
6. Note the small red "c" in the bottom right corner of the note that indicates that this note has been corrected.

To view the original version of the note:

1. Click on the note until it is highlighted.
2. Activate the function F2:Show Detail.
3. Click on the Older Value button.
4. Click on OK to close.

Spell Checking

1. With the Enter Note or Correct Data window open, activate the function F2:Check Spelling.
2. A Spell Checker popup appears and the function keys change. (This is sometimes slow, so be patient.)
3. Questionable words will appear highlighted in the left section of this window. There are several options at this point:
   1. Activate the function F4:Allow Word to accept the word as is; or
   2. Click on the function F2:Correct Word to change the word to the entry labeled "Correction" in the right section of the window; or
   3. Change all occurrences of the misspelled word by activating the function F3:Correct All; or
   4. Click on any of the "Alternates" offered in the right section of the window. The entry labeled "Correction" is replaced by your choice. You can then proceed with any of the above 3 actions; or
   5. Type in your own entry for the "Correction" and proceed with any of the first 3 actions above.
4. The function F6:Clear History erases all the words allowed from memory.

Highlighting Text

For particular emphasis, text can be highlighted in red; however, it is recommended to minimize highlighting as much as possible so as not to diminish its impact when it is used. Note that highlighting applies to an entire note. There are no provisions to emphasize a single word or phrase.

1. Select the note you wish to highlight.
2. Click on the function F7:Highlight On/Off.

Assessments

Entering a Note

1. Open a chart.
   1. Click on the Census button at the very top of the screen. Then select the chart you want to open. Activate the function F1:Open Chart in one of the following 3 ways.
      1. Click on F1: Open Chart button at the very bottom of the screen; or
      2. Tap the F1 key at the top of your keyboard; or
      3. Click and hold the right mouse button until a menu appears, move the mouse over Open Chart, and let go of the button.
   2. Alternatively, you can bypass the Census form by clicking on the Patient button at the very top of the screen; select the chart you want to open from the list presented by clicking on it. Click on Ok.
2. Select section Notes.
3. Select form MD Assess.

   Do Not use the F1:Progress Note function on this form!

4. If this form had not yet been set up, the data section of this form will be completely blank. See the section on Adding Parameters before the next step and before a note can be written.
5. If the form has been set up, there is a column on the left with parameter names separated by group. The parameters should include the note label / interval history (e.g. PICU Progress), Physical Exam, Problems, Medications, and Plan. If the parameter you want is not there, see the section on Adding Parameters. Note that there is a Resident Note grouping and an Attending Note grouping. Please chart only in the appropriate part of the assessment.
6. There is room for two time columns. A note occupies one column. A time column must be added to enter a note. Activate the function F10:Add Time. A small window appears with the current time and date. Hit the Enter key twice if the time and date are okay.

   Either the time or date entry can be changed if desired. Note that this date and time are for purposes of labeling and positioning the note in the chart. The date and time that the note is actually signed, as well as a full revision history (from electronic signature to signature) are stored separately and viewable with the Show Detail function.

   Then click on OK. In some cases, signing for the changes made to the form thus far is advisable.

   Do not use the F11:Chart Now function.

7. Click the left mouse button in a cell in the time column you just added, such as the one in the Physical Exam parameter (row). Note that the lines around this cell turn red, indicating that it is now active.
8. Note the small triangle in the active cell of the form. This is the insertion point for any text you type or insert with the pop-up list.
9. Start typing a sentence, like "History reviewed with the attending on rounds."
10. Use the mouse and click and hold down the left mouse button just to the left of "on rounds."
11. Drag the mouse to highlight "on rounds."
12. Hit the backspace key to delete the highlighted text.
13. Highlight another section of text such as "the attending."
14. Type a word or words such as "Dr. Doolittle." Note that the text you had highlighted is now replaced with the words you had just typed.
15. Now click in the cell in the current time column for the parameter Problems. If a similar note were written within a certain time range, the text from the corresponding cell of that note would be copied forward into this cell. To learn more about this feature, see Copy Forwarding. You must be careful to read and edit your note before you sign for it.

Copying Forward Text

With a mouse click in a current cell, text from the most recent, non-empty, preceding cell of the same parameter can be "copied forward" into that current cell as long as

1. The feature is configured to be on for that parameter, and
2. There is text to be copied from a cell within a specified time range.

Copy forward is generally configured to be off for physical exam and plan parameters.

By clicking on the small cell at the very top of the column that contains the date and time, the text from all the most recent cells (where copy forward is on) are copied into the current time column. This is generally ill-advised.

You must be careful to read and edit your note before you sign for it.

Entering Prewritten Text

1. Click the left mouse button in the cell in which you want to start writing, such as the cell for PICU Progress in the current time column. Note that the lines around this cell turn red, indicating that this is now active.
2. Note also the small triangle cursor in the active cell of the form. This is the insertion point for any text you type or insert with the pop-up list. Click on the point where you would like to insert text.
3. If a list of prewritten text entries has been created for this parameter, it will appear in a pop-up window. Examine this list of potential entries.
4. Note some items on the list are boldfaced. These are headers. Click the left mouse button on one of the headers such as Common. Items in the sublisting below the header collapse and an arrow appears to the left of the header. To expand the sublist, click on the header again. Alternatively, move the mouse cursor so that it lies in this window. Note the window's border becomes green, indicating that this window is "active." Now hit the right- or left-arrow key and note the effect.
5. Click the left mouse button on a non-boldfaced list item to insert a phrase or sentence. Alternatively, use the arrow keys while this window is active and note the effect of each the up-arrow, down-arrow, left-arrow, and right-arrow keys.
6. You can cull or pick out items from the list by typing a few characters. Try slowly typing the first few letters of a common word such as "rales" and watch the effect on the list. To reset the list, hit the space bar. (If this does not reset the list, move the caret to the bottom of the cell, scrolling if necessary and hit the space bar again.)
7. Some lists contain transforms that pull data from other parts of the chart, convert it into text strings, and inserts the data into your note. The existing transforms include:
   • VS Recent
   • CBC Recent
   • Differential Recent
   • Coags Recent
   • Chemistries Recent
   • ABG Recent
8. If the popup window is in your way, just click and hold the left mouse button on the window label at the top and move the box out of your way. To make it disappear altogether, just click on any of the "unselectable" blue areas.

Formatting Assessment Notes

As mentioned above (Reading Notes) Assessment Notes can be viewed from the MD Progress form because of a "transform" that converts those tabular notes into a blob of text. However, this text blob contains little inherent formatting other than parameter labels without hard returns. Here are the two views.

In order to make the note readable in the latter, transformed format, follow these suggestions:

1. Each cell should contain a hard return and a tab at the very bottom.
2. A cell that starts with a list of items (e.g. Problems or occasionally Physical Exam) should contain a hard return at the very top.

To view the formatting of the transformed note, activate the function F2:Show and select Review Assess.

Signing a Note

1. Once you have finished editing your note, you must sign it in order to save it. To do so, click on the function Sign and a small window appears.
2. Enter your password and click on OK (or hit the Enter key).
3. If you want to undo all of your work since your last signing for data (this includes parameters added and text entered), click on the function Cancel. A small window pops up stating "Press Cancel to lose unsigned data, OK to keep." If you wish to lose all of your work since your last signing for data, click on the Cancel button.

You cannot save Assessment Notes as "incomplete" as you can in a Progress Note. However, you can finish the cell on which you are working and come back to finish the remaining cells without having to "correct" those remaining cells.

Editing Text Already Signed

1. Once data in a cell has been signed for, clicking on that cell causes it to be highlighted. Try this with the Interval History in the current time column. To change what has been entered select the function F3:Correct Data.
2. Note the list for this parameter pops up. Continue as previously described to enter prewritten or free text.

Adding Parameters

1. Activate the function F9:Modify Form and a popup table appears. Note the first row of the Actions column has Add as the default.
2. Select a category such as Pediatric Resident Note.
3. Select a single parameter such as PICU Progress, but it is easier to select the macro (identified by the asterisk) that will add all of the parameters necessary for a standard PICU Resident Note.
4. Note that Pediatric Resident Notes is the default entry in the category column of the next parameter to be added. To continue adding parameters in this category, you would select another parameter from this list.
5. To add a problem from a different category, click the cell in the category column where the parameter cell is blank. Now select another category such as Pediatric Attending Note. Now, select a parameter in the next column, either the macro or a single parameter. Then click on OK.
6. Note that new parameters are italicized until you sign for them. (Note also that the grayed-out cells cannot be charted to.) To make your changes permanent, sign for them by clicking on the function Sign. Enter your password in the small window that appears. Click OK or hit the enter key.

Removing Parameters

Rarely, you may want to remove a parameter that is no longer useful. For example, you may want to remove the Physical Exam parameter because your exam is mixed into the body of your problem-based note. Please be considerate of your colleagues who also need to chart on your patient.

1. Select the parameter (in the left-most label column) you wish to remove.
2. Activate the function F9:Modify Form.
3. Make sure the time and date for removing the parameter is appropriate. Click on OK.

   Any cells after the designated date and time are grayed out. If the designated date and time results in an attempt to remove parameters that contain data, an error will occur with the message "Invalid time: D/C or suspend [parameter] after [date time]"

4. Activate the function Sign. Enter your password in the small window that appears. Click OK or hit the enter key.

Alternatively:

1. Activate the function F9:Modify Form.
2. Click the left mouse button in the first cell of the Action column.
3. Select the Action D/C.
4. A list of parameters that exist on your form pops up. Select the parameter you wish to remove, such as Physical Exam.
5. Click on OK.
6. Activate the function Sign. Enter your password in the small window that appears. Click OK or hit the enter key.

Checking Data While Writing a Note

To view other forms for data, you would have to leave the note you are writing. However, you are constrained by the need to Sign or Cancel the data you had already entered before leaving the note-writing form. To circumvent this problem, use Show Related Data.

1. Click the left mouse button in a cell in the current time column in the Physical Exam row.
2. Activate the function F2:Show.
3. Select Show Related Data and a window pops up containing the Vital Signs Trends form. Each parameter can be associated with a different Show Related Data form.
4. Click OK when done.

Spell Checking

A column of text can be checked for spelling errors.

1. Click on any of the cells in the time column you want spell checked.
2. Activate the function F8:Spellcheck Column.
3. A Spell Checker popup appears and the function keys change.
4. Questionable words will appear highlighted in the left section of this window. There are several options at this point:
   1. Activate the function F4:Allow Word to accept the word as is; or
   2. Click on the function F2:Correct Word to change the word to the entry labeled "Correction" in the right section of the window; or
   3. Change all occurrences of the misspelled word by activating the function F3:Correct All; or
   4. Click on any of the "Alternates" offered in the right section of the window. The entry labeled "Correction" is replaced by your choice. You can then proceed with any of the above 3 actions; or
   5. Type in your own entry for the "Correction" and proceed with any of the first 3 actions above.
5. The function F6:Clear History erases all the words allowed from memory.

Highlighting Text

For particular emphasis, text can be highlighted in red; however, it is recommended to minimize highlighting as much as possible so as not to diminish its impact when it is used. Note that highlighting applies to an entire cell. There are no provisions to emphasize a single word or phrase.

1. Select the cell you wish to highlight.
2. Click on the function F7:Highlight On/Off.

Attending Co-Signatures

Although cosignatures by attendings remain a requirement, there are no specific provisions for them in the Continuum 2000 product. Residents, fellows, NPs and SAs are encouraged to record the attending's involvement; and attendings are urged to refer to the residents', fellows', NPs' or SAs' notes in their own notes.

A unique feature of assessment notes does allow for cosignatures of a sort. If the resident and attending chart in the same time column, their electronic signatures will appear together on the same note. Therefore only the physicians of the same service should chart in the same time column.

Printing

The printing function is context-sensitive only to the form currently active. It uses the MD Assessment Report format for Assessment Notes and the MD Notes Report for Progress Notes. The specific notes that are printed from a request are based on the times and dates specified on the Print Report pop-up window.

1. Identify the dates and times of the notes you want printed.
2. Activate the function F11:Print Report.
3. Specify the "Start Time" (and date) and the "End Time" (and date) so that the desired notes are within these boundaries.
4. If you want notes printed from multiple patients, click on the "no" next to "Multiple Patient Select" until it becomes "yes." This may take some time, so be patient. When the list of patients appears, click on each "N" until it becomes "Y" for all patients whose notes will satisfy the above time and date specifications.
5. Click on OK to print.

Summary

In summary, the the following is a list of not-necessarily-intuitive things to keep in mind when using physician documentation in the electronic medical record:

• Make sure you understand the prerequisites, including limits of the text editor and the keys on your keyboard.
• To read all notes sequentially, use Review All.
• Only the primary service should use the assessment notes in MD Assess for daily progress notes with repeating structure. The progress notes in MD Progress can be used by anyone, including the primary service.
• Progress Notes can be saved as "incomplete," but do not become part of the medical record until they are completed.
• Create a new assessment form with F9:Modify Form and use the convenient macro (identified by an asterisk) to add all of the usual parameters for your note.
• Check data without leaving your assessment note by using F2:Show and selecting Show Related Data after selecting a cell.
• Do not use the F1:Progress Note function on the MD Assess form.
• Do not use the F11:Chart Now function on the MD Assess form.
• Format the assessment notes properly with
  1. a hard return and a tab at the bottom of each cell, and
  2. a hard return at the top of each cell that starts with a list
• Primary service attendings should write their assessment notes in the same time column as the resident note to effectively co-sign those notes.
• Remember to sign for all of your data. If you step away from the computer with unsigned data, you seriously risk losing your note unless you have signed for it.

Feedback

The Physician Documentation Implementation Project is still in testing. If you have any feedback on this User Guide or on Physician Documentation in general, please contact Steven Pon.

April 28, 2000 01:45 PM