Physician Documentation

<body stylesrc="emddoc.htm" bgcolor="#FFFFFF"> <p align="center"><font size="5">Physician Documentation in the Electronic Medical Record</font></p> <p align="center"><font size="6"><em><strong>Users' Guide</strong></em></font></p> <p><a name="PageTop"><font size="4">Contents</font></a></p> <dl> </dl> <div align="left"><table border="0" cellpadding="10" cellspacing="1"> <tr> <td valign="top"><dl> <dt><a href="#Introduction">Introduction</a> </dt> <dt><a href="#Prerequisites">Prerequisites</a></dt> <dd><a href="#Passwords">Passwords</a></dd> <dd><a href="#Screen">Screen Layout</a></dd> <dd><a href="#Navigation">Navigation</a></dd> <dd><a href="#TextEditor">The Text Editor</a></dd> <dt><a href="#ReadingNotes">Reading Notes</a></dt> <dd><a href="#ReviewAll">Review All</a></dd> <dd><a href="#Directory">Directory</a></dd> <dd><a href="#MDProgress">MD Progress</a></dd> <dt><a href="#ProgressNotes">Progress Notes</a></dt> <dd><a href="#EnterPrg">Entering a Note</a></dd> <dd><a href="#PrewrittenPrg">Entering Prewritten Text</a> </dd> <dd><a href="#SigningPrg">Signing a Note</a></dd> <dd><a href="#EditingPrg">Editing Text Already Signed</a> </dd> <dd><a href="#SpellCheckPrg">Spell Checking</a> </dd> <dd><a href="#HighlightPrg">Highlighting Text</a> </dd> </dl> </td> <td valign="top"><dl> <dt><a href="#Assessments">Assessments</a></dt> <dd><a href="#EnterAsm">Entering a Note</a> </dd> <dd><a href="#CopyForward">Copying Forward Data</a> </dd> <dd><a href="#PrewrittenAsm">Entering Prewritten Text</a> </dd> <dd><a href="#Formatting">Formatting Assessment Notes</a> </dd> <dd><a href="#SigningAsm">Signing a Note</a> </dd> <dd><a href="#EditingAsm">Editing Text Already Signed</a> </dd> <dd><a href="#Adding">Adding Parameters</a> </dd> <dd><a href="#Removing">Removing Parameters</a> </dd> <dd><a href="#CheckingData">Checking Data While Writing a Note</a> </dd> <dd><a href="#SpellCheckAsm">Spell Checking</a> </dd> <dd><a href="#HighlightAsm">Highlighting Text</a> </dd> <dt><a href="#Co-Signatures">Attending Co-Signatures</a> </dt> <dt><a href="#Printing">Printing</a></dt> <dt><a href="#Summary">Summary</a></dt> <dt><a href="#Feedback">Feedback</a></dt> </dl> </td> </tr> </table> </div><dl> <dt> </dt> </dl> <p><a name="Introduction"><font size="5">Introduction</font></a><font size="5"> </font><a href="#PageTop"><font size="5"><img src="../../images/gotop.gif" alt="Go to top of page" border="0" width="16" height="16"></font></a></p> <p>There are at least two ways for physicians to enter a note into the Eclipsys Continuum 2000 electronic medical record, <em>Progress Notes</em> and <em>Assessment Notes</em>. There are advantages and disadvantages of each method. (See <a href="notetype.htm">summary table</a> 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 <em>parameters</em> and <em>time</em> 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 <em>copy forwarded</em> to a new time column.</p> <p><font color="#FF0000">Suggested usage:</font> <em>Assessment Notes</em> 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 <u>not</u> be used by consulting services. <em>Progress Notes</em> 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.</p> <p>These notes are also designed with the requirements of the Health Care Finance Administration's regulations (IL-273) in mind. </p> <p><a name="Prerequisites"><font size="5">Prerequisites</font></a><font size="5"> </font><a href="#PageTop"><font size="5"><img src="../../images/gotop.gif" alt="Go to top of page" border="0" width="16" height="16"></font></a></p> <p><a name="Passwords"><strong>Passwords</strong></a><strong> </strong><a href="#Prerequisites"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>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 <em>Esc</em> key.</p> <p>The generic password that allows you to view data <u>does not</u> allow you to enter data, including notes.</p> <p><a name="Screen"><strong>Screen Layout</strong></a><strong> </strong><a href="#Prerequisites"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>Acquaint yourself with the various rows of buttons: <i>Sections</i> and <i>Forms</i> near the top of the screen, and <i>Functions</i> along the bottom. <em>Section</em> buttons are constant; whereas the <em>forms</em> buttons change whenever a different <em>Section</em> is selected. The <em>function</em> buttons change with the context of the task at hand. <i>Functions</i> can be invoked in any of 3 ways:</p> <ol> <li>use the mouse and click on the <i>function</i> button on the screen with the left mouse button; </li> <li>strike the key on the keyboard that corresponds to the <i>function</i> button on the screen; or </li> <li>click and hold the <u>right</u> mouse button to get a menu to pop up on your screen, then use the mouse to choose the <i>function</i>, releasing the button to select it.</li> </ol> <p><img src="emrlayot.gif" width="1024" height="813"></p> <p>Look for the <em>Message Box</em>, a short but wide white rectangle just above the <em>function</em> buttons. Look in this area for messages from the system, particularly if a mouse click causes a gong to sound.</p> <p>Also note the <em>Login</em>, <em>Logout</em>, <em>Census</em>, <em>Patient</em>, and <em>Utility</em> buttons along the very top of the screen. Their functions are somewhat self-explanatory. There is a blue <em>Visit</em> button that becomes active within a patient chart. This button allows you to view the patient's records of prior hospitalizations. </p> <p><a name="Navigation"><strong>Navigation</strong></a><strong> </strong><a href="#Prerequisites"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>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. </p> <p>If a vertical <em>scroll bar</em> appears on the right of a form, there is more data to be viewed on that form. Many forms have <em>scroll labels</em> 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 <em>Page Up</em> and <em>Page Down</em> buttons on your keyboard (<em>Page Up</em> or <em>9</em>; and <em>Page Down</em> or <em>3</em> on your numeric keypad at the far right of the keyboard, <u>not</u> the 6-key pad with the <em>Insert</em>, <em>Delete</em>, <em>Home</em>, <em>End</em>, <em>Page Up</em>, and <em>Page Down</em> keys) can also help you navigate up and down a form. Be sure that the <em>Num[ber] Lock</em> light on your keyboard is <u>off</u>. If it is on, tap the <em>Num Lock</em> key on your keyboard until it goes off. Vertical <em>scroll bars</em> can also appear <u>within</u> a cell if there is more data in a cell than can be viewed in the space available. </p> <p>If a horizontal <em>scroll bar</em> appears on the bottom of a form, the form can be navigated back and forth through time. The <em>Newer (Home</em> or <em>7)</em> and <em>Older (End</em> or <em>1)</em> buttons on your numeric keypad can also help you navigate through time. Be sure that the <em>Num Lock</em> light on your keyboard is <u>off</u>.</p> <p><a name="TextEditor"><strong>Text Editor/Word Processor</strong></a><strong> </strong><a href="#Prerequisites"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>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 <strong>can cause you to lose your work</strong>, so please be careful. </p> <ul> <li>The 6 keys just to the right of the <em>Enter</em> key and usually labeled <em>Insert</em>, <em>Delete</em>, <em>Home</em>, <em>End</em>, <em>Page Up</em>, and <em>Page Down</em> are "mapped" to entirely different functions: <em>Ok</em>, <em>Sign</em>, <em>More</em>, <em>Command</em>, <em>Cancel</em>, and <em>Census</em>. While this mapping appears to vary with context, I would <u>not</u> use these keys. Of particular concern it the <em>Page Up</em> key mapped to <em>Cancel</em>. Hitting this key will erase all of your unsigned work.</li> </ul> <blockquote> <blockquote> <table border="1" cellspacing="1"> <tr> <td align="center" width="30%"><em>Insert</em><br> OK</td> <td align="center" width="30%"><em>Home</em><br> More</td> <td align="center" width="30%"><em>Page Up</em><br> Cancel</td> </tr> <tr> <td align="center" width="30%"><em>Delete</em><br> Sign</td> <td align="center" width="30%"><em>End</em><br> Command </td> <td align="center" width="30%"><em>Page Down</em><br> Census</td> </tr> </table> </blockquote> </blockquote> <ul> <li>Use the <em>Backspace</em> key to delete text. The <em>Shift-Backspace</em> combination deletes the character to the right of the cursor (<em>Progress Notes</em> only, <u>not</u> in <em>Assessment Notes</em>). The <em>Delete</em> key does <u>not</u> act the way you would expect other Windows applications to act. See above.</li> <li>Selecting Text<ul> <li>Using the mouse, click and hold while dragging across the desired text.</li> <li>Double-click to select a word.</li> <li>Triple-click to select a paragraph.</li> <li><em>Shift-left</em> and <em>right arrow</em> keys select one character at a time.</li> <li><em>Shift-up</em> and <em>down arrow</em> keys select one line at a time.</li> <li><em>Shift-End</em>* selects to the end of the line.</li> <li><em>Shift-Home</em>* selects to the beginning of the line.<br> * Not consistently mapped on every workstation.</li> </ul> </li> <li>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.</li> <li>Cursor Navigation<ul> <li><em>Ctrl-left</em> or <em>right arrow</em> moves the cursor one word to the left or right.</li> <li><em>Ctrl-up</em> or <em>down arrow</em> moves the cursor up or down one paragraph. (<em>Ctrl-up arrow</em> sometimes gets stuck at the top of the current paragraph and goes no further.)</li> </ul> </li> <li>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!</li> <li>Portions of an unsigned note can be selected then <strong>cut, copied or pasted</strong> using the standard Windows key combinations for these functions. Entire notes or cells, once signed for, can be copied using the "Copy Note" function.<ul> <li><em>Ctrl-X</em> or <em>Shift-Delete</em>* for cut</li> <li><em>Ctrl-C</em> or <em>Ctrl-Insert</em>* for copy</li> <li><em>Ctrl-V</em> or <em>Shift-Insert</em>* for paste<br> * Not consistently mapped on every workstation.</li> </ul> </li> <li>Copying Signed Notes<ul> <li>These word-processing functions work only on unsigned data. To copy signed notes, click on the note so that it is highlighted. Activate the <em>function</em> <strong>F3:Copy Note</strong> in one of the following 3 ways.<ol> <li>Click on <strong>F3:Copy Note</strong> button at the very bottom of the screen; or</li> <li>Tap the <strong>F3</strong> key at the top of your keyboard; or</li> <li>Click and hold the right mouse button until a menu appears, move the mouse over <strong>Copy Note</strong>, and let go of the button.</li> </ol> </li> <li>Once you have copied the note, you can paste it anywhere using <em>Ctrl-V</em> as above.</li> <li>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 <em>Assessment Notes</em> that have been "transformed" into the format of a <em>Progress Note</em> for viewing only. To select and copy these notes you must use the <strong>MD Assess</strong> <em>form</em>. On that form, you can only select and copy one cell at a time.</li> </ul> </li> <li>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 <em>Ctrl-C</em> and subsequently paste it into a note in Eclipsys with <em>Ctrl-V</em>. (The caution is that selecting <strong>anything</strong> in Eclipsys will cause it to replace <strong>everything</strong> in this buffer, making it difficult to replace a block of text with the buffered text. Windows applications do not behave this way.)</li> </ul> <p><a name="ReadingNotes"><font size="5">Reading Notes</font></a><font size="5"> </font><a href="#PageTop"><font size="5"><img src="../../images/gotop.gif" alt="Go to top of page" border="0" width="16" height="16"></font></a></p> <p><a name="ReviewAll"><strong>Review All</strong></a><strong> </strong><a href="#ReadingNotes"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>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 <strong>Review All</strong> <em>form</em> in the <strong>Notes</strong> <em>section</em>. This form is multidisciplinary and includes all physician, nursing, and ancillary notes. This <em>form</em> is <em>review only</em>, meaning none of the notes can be altered from this <em>form</em>. See <a href="#Navigation">Navigation</a> for more information on moving about this form.</p> <p><a name="Directory"><strong>Directory</strong></a> <a href="#ReadingNotes"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>Look in the <strong>Directory</strong> that lists notes by their <em>subtopic</em> (for <em>Progress Notes</em>) or <em>parameter</em> (for <em>Assessment Notes</em>). To view a note:</p> <ol> <li>Click on the title until it is highlighted. </li> <li>Activate the <em>function</em> <strong>F2:Show Detail</strong>. </li> </ol> <p><img src="emrnodir.gif" width="829" height="259"></p> <p>A small red "<font color="#FF0000">c</font>" is visible at the far right of a directory entry indicates a corrected note. To view the correction history</p> <ol> <li>Click on the title until it is highlighted.</li> <li>Activate the <em>function</em> <strong>F2:Show Detail</strong>.</li> <li>Click on the <strong>Older Value</strong> button.</li> <li>Click on <strong>OK</strong> to close.</li> </ol> <p>To cull the directory for a specific kind of note: <img src="emrselno.gif" width="647" height="168"></p> <ol> <li>Activate the <em>function</em> <strong>F8:Select Notes</strong>. </li> <li>Select notes by <em>Topic/Subtopic</em> (or <em>Category/Parameter</em>). </li> <li>Click on the title of the note you wish to view until it is highlighted.</li> <li>Activate the <em>function</em> <strong>F2:Show Detail</strong>. </li> </ol> <p>Some notes (specifically the ones entitled "Assessment" or "Shift Assessment") are not viewable, these are the <em>Assessment Notes</em> that require the tabular format; however, all of these notes are "transformed" into the <em>Progress Note</em> format that can be viewed. Therefore, a message "Must use form where assessment was entered for any further action" in the <a href="#Screen">Message Box</a> should not discourage you; just look for the "transformed" note that can be identified by the identical time stamp and the red "<font color="#FF0000">Assessment</font>" label in the right column.</p> <p>If you try to leave this form but are unable to, look in the <a href="#Screen">Message Box</a>. If the message is "Cannot leave form with unsigned data," hit the <em>Cancel</em> button. A window pops up with the message "Press Cancel to lose unsigned data, OK to keep." Click on the <em>Cancel</em> button in this box. You should be able to leave this form now.</p> <p><a name="MDProgress"><strong>MD Progress</strong></a><strong> </strong><a href="#ReadingNotes"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p><strong>MD Progress</strong> Notes cannot be viewed from the <strong>MD Assess</strong> <em>form</em> (except if a <strong>Show Related Data</strong> <em>form</em> is configured to <strong>MD Progress</strong>), but <em>Assessment Notes</em> can be viewed from the <strong>MD Progress</strong> <em>form</em> 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 <strong>Review All</strong> <em>form</em>. </p> <p>If more than one user has signed for data in the same column on the <strong>MD Assess</strong> form, each section of the transformed note is prefaced with an author's label.</p> <p><a name="ProgressNotes"><font size="5">Progress Notes</font></a><font size="5"> </font><a href="#PageTop"><font size="5"><img src="../../images/gotop.gif" alt="Go to top of page" border="0" width="16" height="16"></font></a></p> <p><a name="EnterPrg"><font size="4">Entering a Note</font></a><font size="4"> </font><a href="#ProgressNotes"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <ol> <li>Open a chart. <ol> <li>Click on the <strong>Census</strong> button at the very top of the screen. Then Click on the chart you want to open until it is highlighted. Activate the <em>function</em> <strong>F1:Open Chart</strong> in one of the following 3 ways.<ol> <li>Click on <strong>F1:Open Chart</strong> button at the very bottom of the screen; or</li> <li>Tap the <strong>F1</strong> key at the top of your keyboard; or</li> <li>Click and hold the right mouse button until a menu appears, move the mouse over <strong>Open Chart</strong>, and let go of the button.</li> </ol> </li> <li>Alternatively, you can bypass the <strong>Census</strong> form by clicking on the <strong>Patient</strong> 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 <strong>Ok</strong>.</li> </ol> </li> <li>Select <i>section</i> <b>Notes</b>. </li> <li>Select <i>form</i> <b>MD Progress</b>. </li> <li>Activate the <em>function</em> <strong>F5:Enter Note</strong>. </li> <li>A <em>Enter Note</em> window appears. Hit the <em>Enter</em> key twice if the time and date are okay. <p>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 <strong>Show Detail</strong> <em>function</em>. <img src="emrprgno.gif" width="743" height="281"></p> </li> <li>Select a <em>Topic</em> with the mouse (directly under the time or date) or right-arrow key. Try "MD Notes Pediatric". </li> <li>Select a <em>Subtopic</em>, such as "Pediatric Resident Note". If no appropriate <em>subtopic</em> 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 <a href="#Feedback">Feedback</a>.)</li> <li>Click the left mouse button in the <em>Text</em> area below <em>Associated Dx</em>.</li> <li>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. </li> <li>Start typing a sentence, like "Interval history reviewed and patient examined with the attending on rounds." </li> <li>Use the mouse. Click and hold down the left mouse button in the text, just to the left of "on rounds." </li> <li>Drag the mouse to highlight "on rounds." </li> <li>Hit the <b>backspace</b> key to delete the highlighted text. </li> <li>Highlight another section of text such as "the attending." </li> <li>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. </li> </ol> <p><a name="PrewrittenPrg"><font size="4">Entering Prewritten Text</font></a><font size="4"> </font><a href="#ProgressNotes"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <ol> <li><img src="emrtxtls.gif" align="right" hspace="0" width="345" height="561">Click the left mouse button in the <em>Text</em> area just below <em>Associated Dx</em>. </li> <li>If a list of prewritten text entries has been created for this subtopic, it will appear in a pop-up window. Examine this list.</li> <li>Note some items on the list are boldfaced. These are headers. Click the left mouse button on one of the <i>headers</i>. Items in the sublisting below the <i>header</i> collapse and an arrow appears to the left of the <i>header</i>. To expand the sublist, click on the <i>header</i> 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 <em>right-</em> or l<em>eft-arrow</em> key and note the effect.</li> <li>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 <em>up-arrow</em>, <em>down-arrow</em>, <em>left-arrow</em>, and <em>right-arrow</em> keys.</li> <li>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 <em>space bar</em>. (If this does not reset the list, move the caret to the bottom of the note and hit the <em>space bar</em> again.) </li> <li>Some lists contain <em>transforms</em> 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:<ul> <li>VS Recent</li> <li>CBC Recent</li> <li>Differential Recent</li> <li>Coags Recent</li> <li>Chemistries Recent</li> <li>ABG Recent</li> </ul> </li> <li>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. </li> </ol> <p><a name="SigningPrg"><font size="4">Signing a Note</font></a><font size="4"> </font><a href="#ProgressNotes"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>You <u>must</u> then sign it with your electronic signature in order to save it.</p> <ol> <li><img src="emrsign.gif" align="right" hspace="0" width="354" height="111">Once you have finished editing your note, click on the <strong>OK</strong> at the bottom of the <em>Enter Note</em> window. </li> <li>Activate the <i>function</i> <b>Sign</b> at the bottom of the window, and another small window will appear. </li> <li>Enter your password and click on <b>OK</b> in the little pop-up window (or hit the Enter key). </li> </ol> <p>If you want to undo <u>all</u> of your work since your last signing for data, activate the <i>function</i> <b>Cancel</b>. 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 <b>Cancel</b> button. </p> <p>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 <strong>OK</strong> 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.</p> <p><a name="EditingPrg"><font size="4">Editing Text Already Signed</font></a><font size="4"> </font><a href="#ProgressNotes"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <ol> <li>Once data in a cell has been signed, clicking on that note causes it to be highlighted. <p>Note that some notes are not selectable, these are <em>Assessment Notes</em> that have been "transformed" into the format of a <em>Progress Note</em> for viewing only. Editing these notes must be done in the <strong>MD Assess</strong> <em>form</em>.</p> </li> <li>To change what has been entered, activate the <i>function</i> <b>F3:Correct Data</b>. Make corrections to the note.</li> <li>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.) </li> <li>Click on the <strong>OK</strong> button at the bottom of the window.</li> <li>Sign the note.</li> <li>Note the small red "<font color="#FF0000">c</font>" in the bottom right corner of the note that indicates that this note has been corrected.</li> </ol> <p>To view the original version of the note:</p> <ol> <li>Click on the note until it is highlighted.</li> <li>Activate the <em>function</em> <strong>F2:Show Detail</strong>.</li> <li>Click on the <strong>Older Value</strong> button.</li> <li>Click on <strong>OK</strong> to close.</li> </ol> <p><a name="SpellCheckPrg"><font size="4">Spell Checking</font></a><font size="4"> </font><a href="#ProgressNotes"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <ol> <li>With the <em>Enter Note</em> or <em>Correct Data</em> window open, activate the <i>function</i> <b>F2:Check Spelling</b>. </li> <li>A <em>Spell Checker</em> popup appears and the function keys change. (This is sometimes slow, so be patient.) <img src="emrsplfx.gif" width="778" height="58"></li> <li>Questionable words will appear highlighted in the left section of this window. There are several options at this point: <ol> <li>Activate the <i>function</i> <b>F4:Allow Word</b> to accept the word as is; or </li> <li>Click on the <i>function</i> <b>F2:Correct Word</b> to change the word to the entry labeled "Correction" in the right section of the window; or</li> <li>Change all occurrences of the misspelled word by activating the function <strong>F3:Correct All</strong>; or</li> <li>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</li> <li>Type in your own entry for the "Correction" and proceed with any of the first 3 actions above.</li> </ol> </li> <li>The <em>function</em> <strong>F6:Clear History</strong> erases all the words allowed from memory. <img src="emrspell.gif" width="641" height="474"></li> </ol> <p><a name="HighlightPrg"><font size="4">Highlighting Text</font></a><font size="4"> </font><a href="#ProgressNotes"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>For particular emphasis, text can be highlighted in red; however, it is recommended to <u>minimize</u> highlighting as much as possible so as not to diminish its impact when it is used. Note that highlighting applies to an <u>entire</u> note. There are no provisions to emphasize a single word or phrase.</p> <ol> <li>Select the note you wish to highlight.</li> <li>Click on the <i>function</i> <b>F7:Highlight On/Off</b>. </li> </ol> <p><a name="Assessments"><font size="5">Assessments</font></a><font size="5"> </font><a href="#PageTop"><font size="5"><img src="../../images/gotop.gif" alt="Go to top of page" border="0" width="16" height="16"></font></a></p> <p><a name="EnterAsm"><font size="4">Entering a Note</font></a><font size="4"> </font><a href="#Assessments"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <ol> <li>Open a chart. <ol> <li>Click on the <strong>Census</strong> button at the very top of the screen. Then select the chart you want to open. Activate the <em>function</em> <strong>F1:Open Chart</strong> in one of the following 3 ways.<ol> <li>Click on <strong>F1: Open Chart</strong> button at the very bottom of the screen; or</li> <li>Tap the <strong>F1</strong> key at the top of your keyboard; or</li> <li>Click and hold the right mouse button until a menu appears, move the mouse over <strong>Open Chart</strong>, and let go of the button.</li> </ol> </li> <li>Alternatively, you can bypass the <strong>Census</strong> form by clicking on the <strong>Patient</strong> 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 <strong>Ok</strong>.</li> </ol> </li> <li>Select <i>section</i> <b>Notes</b>. </li> <li>Select <i>form</i> <b>MD Assess</b>. <p><font color="#FF0000">Do Not use the <strong>F1:Progress Note</strong> function on this form!</font></p> </li> <li>If this form had not yet been set up, the data section of this form will be completely blank. See the section on <a href="#Adding">Adding Parameters</a> before the next step and before a note can be written.</li> <li>If the form has been set up, there is a column on the left with <i>parameter</i> names separated by <i>group</i>. The parameters should include the note label / interval history (e.g. <strong>PICU Progress</strong>), <b>Physical Exam</b>, <strong>Problems</strong>, <strong>Medications</strong>, and <strong>Plan</strong>. If the <em>parameter</em> you want is not there, see the section on <a href="#Adding">Adding Parameters</a>. Note that there is a Resident Note <em>grouping</em> and an Attending Note <em>grouping</em>. Please chart only in the appropriate part of the <em>assessment</em>.</li> <li>There is room for two time columns. A note occupies one column. A time column must be added to enter a note. Activate the <i>function</i> <b>F10:Add Time</b>. A small window appears with the current time and date. Hit the <em>Enter</em> key twice if the time and date are okay. <img src="emradtim.gif" width="706" height="421"> <p>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 <strong>Show Detail</strong> <em>function</em>.</p> <p>Then click on <b>OK</b>. In some cases, signing for the changes made to the <em>form</em> thus far is advisable.</p> <p>Do <u>not</u> use the <strong>F11:Chart Now</strong> <em>function</em>.</p> </li> <li>Click the left mouse button in a cell in the time column you just added, such as the one in the <b>Physical Exam</b> <em>parameter</em> (row). Note that the lines around this cell turn red, indicating that it is now active.</li> <li>Note the small triangle in the active cell of the <i>form</i>. This is the insertion point for any text you type or insert with the pop-up list. </li> <li>Start typing a sentence, like "History reviewed with the attending on rounds." </li> <li>Use the mouse and click and hold down the left mouse button just to the left of "on rounds." </li> <li>Drag the mouse to highlight "on rounds." </li> <li>Hit the <em>backspace</em> key to delete the highlighted text. </li> <li>Highlight another section of text such as "the attending." </li> <li>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. </li> <li>Now click in the cell in the current time column for the <em>parameter</em> <strong>Problems</strong>. If a similar note were written within a certain time range, the text from the corresponding cell of that note would be <em><strong>copied forward</strong></em> into this cell. To learn more about this feature, see <a href="#CopyForward">Copy Forwarding</a>. You <u>must</u> be careful to read and edit your note before you sign for it. </li> </ol> <p><a name="CopyForward"><font size="4">Copying Forward Text</font></a><font size="4"> </font><a href="#Assessments"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>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</p> <ol> <li>The feature is configured to be <u>on</u> for that parameter, and </li> <li>There is text to be copied from a cell within a specified time range.</li> </ol> <p>Copy forward is generally configured to be <u>off</u> for physical exam and plan parameters. </p> <p>By clicking on the small cell at the very top of the column that contains the date and time, the text from <u>all</u> the most recent cells (where copy forward is on) are copied into the current time column. This is generally ill-advised.</p> <p>You <u>must</u> be careful to read and edit your note before you sign for it. </p> <p><a name="PrewrittenAsm"><font size="4">Entering Prewritten Text</font></a><font size="4"> </font><a href="#Assessments"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <ol> <li>Click the left mouse button in the cell in which you want to start writing, such as the cell for <b>PICU Progress</b> in the current time column. Note that the lines around this cell turn red, indicating that this is now active. </li> <li>Note also the small triangle cursor in the active cell of the <i>form</i>. 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.</li> <li>If a list of prewritten text entries has been created for this <em>parameter</em>, it will appear in a pop-up window. Examine this list of potential entries. </li> <li>Note some items on the list are boldfaced. These are <em>headers</em>. Click the left mouse button on one of the <i>headers</i> such as <b>Common</b>. Items in the sublisting below the <i>header</i> collapse and an arrow appears to the left of the <i>header</i>. To expand the sublist, click on the <i>header</i> 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 <em>right-</em> or l<em>eft-arrow</em> key and note the effect. </li> <li>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 <em>up-arrow</em>, <em>down-arrow</em>, <em>left-arrow</em>, and <em>right-arrow</em> keys. </li> <li>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 <em>space bar</em>. (If this does not reset the list, move the caret to the bottom of the cell, scrolling if necessary and hit the <em>space bar</em> again.)</li> <li>Some lists contain <em>transforms</em> 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:<ul> <li>VS Recent</li> <li>CBC Recent</li> <li>Differential Recent</li> <li>Coags Recent</li> <li>Chemistries Recent</li> <li>ABG Recent</li> </ul> </li> <li>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. </li> </ol> <p><a name="Formatting"><font size="4">Formatting Assessment Notes</font></a><font size="4"> </font><a href="#Assessments"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>As mentioned above (<a href="#ReadingNotes">Reading Notes</a>) <em>Assessment Notes</em> can be viewed from the <strong>MD Progress</strong> <em>form</em> because of a "transform" that converts those tabular notes into a blob of text. However, this text blob contains little inherent formatting other than <em>parameter</em> labels without hard returns. Here are the two views.</p> <p><img src="emrasmv1.gif" width="704" height="324"></p> <p><img src="emrasmv2.gif" width="769" height="354"></p> <p>In order to make the note readable in the latter, transformed format, follow these <font color="#FF0000">suggestions:</font> </p> <ol> <li>Each cell should contain a <u>hard return and a tab</u> at the very bottom.</li> <li>A cell that starts with a list of items (e.g. <strong>Problems</strong> or occasionally <strong>Physical Exam</strong>) should contain a <u>hard return</u> at the very top.</li> </ol> <p>To view the formatting of the transformed note, activate the <em>function</em> <strong>F2:Show</strong> and select <strong>Review Assess</strong>.</p> <p><a name="SigningAsm"><font size="4">Signing a Note</font></a><font size="4"> </font><a href="#Assessments"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <ol> <li>Once you have finished editing your note, you <u>must</u> sign it in order to save it. To do so, click on the <i>function</i> <b>Sign</b> and a small window appears. <img src="emrsign.gif" align="right" hspace="0" width="354" height="111"></li> <li>Enter your password and click on <b>OK</b> (or hit the Enter key). </li> <li>If you want to undo <u>all</u> of your work since your last signing for data (this includes parameters added and text entered), click on the <i>function</i> <b>Cancel</b>. 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 <b>Cancel</b> button. </li> </ol> <p>You cannot save <em>Assessment Notes</em> as "incomplete" as you can in a <a href="#SigningPrg"><em>Progress Note</em></a>. 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.</p> <p><a name="EditingAsm"><font size="4">Editing Text Already Signed</font></a><font size="4"> </font><a href="#Assessments"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <ol> <li>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 <i>function</i> <b>F3:Correct Data</b>. </li> <li>Note the list for this parameter pops up. Continue as previously described to enter prewritten or free text. </li> </ol> <p><a name="Adding"><font size="4">Adding Parameters</font></a><font size="4"> </font><a href="#Assessments"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <ol> <li>Activate the <i>function</i> <b>F9:Modify Form</b> and a popup table appears. Note the first row of the <i>Actions</i> column has <b>Add</b> as the default. </li> <li>Select a <i>category</i> such as <b>Pediatric Resident Note</b>. <img src="emrmodfm.gif" width="938" height="226"></li> <li>Select a single <i>parameter</i> such as <b>PICU Progress</b>, but it is easier to select the macro (identified by the asterisk) that will add all of the parameters necessary for a standard <strong>PICU Resident Note</strong>. </li> <li>Note that <b>Pediatric Resident Notes</b> is the default entry in the <i>category</i> column of the next <i>parameter</i> to be added. To continue adding <em>parameters</em> in this category, you would select another <i>parameter</i> from this list.</li> <li>To add a problem from a different category, click the cell in the <i>category</i> column where the <em>parameter</em> cell is blank. Now select another <i>category</i> such as <b>Pediatric Attending Note</b>. Now, select a <i>parameter</i> in the next column, either the macro or a single <em>parameter</em>. Then click on <b>OK</b>. </li> <li>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 <i>function</i> <b>Sign</b>. Enter your password in the small window that appears. Click <strong>OK</strong> or hit the <em>enter</em> key.</li> </ol> <p><a name="Removing"><font size="4">Removing Parameters</font></a><font size="4"> </font><a href="#Assessments"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>Rarely, you may want to remove a <em>parameter</em> that is no longer useful. For example, you may want to remove the <strong>Physical Exam</strong> 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.</p> <ol> <li>Select the <em>parameter</em> (in the left-most label column) you wish to remove. </li> <li>Activate the <i>function</i> <b>F9:Modify Form</b>. </li> <li>Make sure the time and date for removing the parameter is appropriate. Click on <b>OK</b>. <p>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]"</p> </li> <li>Activate the <i>function</i> <b>Sign</b>. Enter your password in the small window that appears. Click <strong>OK</strong> or hit the <em>enter</em> key.</li> </ol> <p>Alternatively: <img src="emrmodax.gif" align="right" hspace="0" width="171" height="208"></p> <ol> <li>Activate the <i>function</i> <b>F9:Modify Form</b>. </li> <li>Click the left mouse button in the first cell of the <b>Action</b> column. </li> <li>Select the <i>Action</i> <b>D/C</b>.</li> <li>A list of <i>parameters</i> that exist on your form pops up. Select the <i>parameter</i> you wish to remove, such as <b>Physical Exam</b>. </li> <li>Click on <b>OK</b>. </li> <li>Activate the <i>function</i> <b>Sign</b>. Enter your password in the small window that appears. Click <strong>OK</strong> or hit the <em>enter</em> key.</li> </ol> <p><a name="CheckingData"><font size="4">Checking Data While Writing a Note</font></a><font size="4"> </font><a href="#Assessments"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>To view other <i>forms</i> for data, you would have to leave the note you are writing. However, you are constrained by the need to <b>Sign</b> or <b>Cancel</b> the data you had already entered before leaving the note-writing <i>form</i>. To circumvent this problem, use <b>Show Related Data</b>.</p> <ol> <li>Click the left mouse button in a cell in the current time column in the <b>Physical Exam </b>row. </li> <li>Activate the <i>function</i> <b>F2:Show</b>. </li> <li>Select <b>Show Related Data</b> and a window pops up containing the <b>Vital Signs Trends</b> <i>form</i>. Each parameter can be associated with a different <b>Show Related Data</b> <em>form</em>.</li> <li>Click <strong>OK</strong> when done.</li> </ol> <p><a name="SpellCheckAsm"><font size="4">Spell Checking</font></a><font size="4"> </font><a href="#Assessments"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>A column of text can be checked for spelling errors. </p> <ol> <li>Click on any of the cells in the time column you want spell checked. </li> <li>Activate the <i>function</i> <b>F8:Spellcheck Column</b>. </li> <li>A <em>Spell Checker</em> popup appears and the function keys change. </li> <li>Questionable words will appear highlighted in the left section of this window. There are several options at this point: <ol> <li>Activate the <i>function</i> <b>F4:Allow Word</b> to accept the word as is; or </li> <li>Click on the <i>function</i> <b>F2:Correct Word</b> to change the word to the entry labeled "Correction" in the right section of the window; or</li> <li>Change all occurrences of the misspelled word by activating the function <strong>F3:Correct All</strong>; or</li> <li>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</li> <li>Type in your own entry for the "Correction" and proceed with any of the first 3 actions above.</li> </ol> </li> <li>The <em>function</em> <strong>F6:Clear History</strong> erases all the words allowed from memory.</li> </ol> <p><a name="HighlightAsm"><font size="4">Highlighting Text</font></a><font size="4"> </font><a href="#Assessments"><strong><img src="../../images/goup.gif" alt="Go to top of section" border="0" width="16" height="16"></strong></a></p> <p>For particular emphasis, text can be highlighted in red; however, it is recommended to <u>minimize</u> highlighting as much as possible so as not to diminish its impact when it is used. Note that highlighting applies to an <u>entire</u> cell. There are no provisions to emphasize a single word or phrase.</p> <ol> <li>Select the cell you wish to highlight.</li> <li>Click on the <i>function</i> <b>F7:Highlight On/Off</b>. </li> </ol> <p><a name="Co-Signatures"><font size="5">Attending Co-Signatures</font></a><font size="5"> </font><a href="#PageTop"><font size="5"><img src="../../images/gotop.gif" alt="Go to top of page" border="0" width="16" height="16"></font></a></p> <p>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.</p> <p>A unique feature of <em>assessment notes</em> 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 <u>only</u> the physicians of the <u>same</u> service should chart in the same time column.</p> <p><a name="Printing"><font size="5">Printing</font></a><font size="5"> </font><a href="#PageTop"><font size="5"><img src="../../images/gotop.gif" alt="Go to top of page" border="0" width="16" height="16"></font></a></p> <p>The printing function is context-sensitive only to the <em>form</em> currently active. It uses the <strong>MD Assessment Report</strong> format for <em>Assessment Notes</em> and the <strong>MD Notes Report</strong> for <em>Progress Notes</em>. The specific notes that are printed from a request are based on the times and dates specified on the <em>Print Report</em> pop-up window.</p> <ol> <li>Identify the dates and times of the notes you want printed. <img src="emrprnt.gif" width="695" height="371"></li> <li>Activate the function <strong>F11:Print Report</strong>.</li> <li>Specify the "Start Time" (and date) and the "End Time" (and date) so that the desired notes are within these boundaries.</li> <li>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.</li> <li>Click on <strong>OK</strong> to print.</li> </ol> <p><a name="Summary"><font size="5">Summary</font></a><font size="5"> </font><a href="#PageTop"><font size="5"><img src="../../images/gotop.gif" alt="Go to top of page" border="0" width="16" height="16"></font></a></p> <p><font size="3">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:</font></p> <ul> <li>Make sure you understand the <a href="#Prerequisites">prerequisites</a>, including limits of the <a href="#TextEditor">text editor</a> and the keys on your <a href="#Navigation">keyboard</a>.</li> <li>To read all notes sequentially, use <a href="#ReadingNotes"><strong>Review All</strong></a>.</li> <li><font size="3">Only the primary service should use the <em>assessment notes</em> in </font><a href="#Introduction"><font size="3"><strong>MD Assess</strong></font></a><font size="3"> for daily progress notes with repeating structure. The <em>progress notes</em> in </font><a href="#Introduction"><font size="3"><strong>MD Progress</strong></font></a><font size="3"> can be used by anyone, including the primary service.</font></li> <li><font size="3"><em>Progress Notes</em> can be saved as "</font><a href="#SigningPrg"><font size="3">incomplete</font></a><font size="3">," but do not become part of the medical record until they are completed.</font></li> <li><font size="3">Create a new <em>assessment</em> form with </font><a href="#Adding"><font size="3"><strong>F9:Modify Form</strong></font></a><font size="3"> and use the convenient macro (identified by an asterisk) to add all of the usual <em>parameters</em> for your note.</font></li> <li><font size="3">Check data without leaving your <em>assessment note</em> by using <strong>F2:Show</strong> and selecting </font><a href="#CheckingData"><font size="3"><strong>Show Related Data</strong></font></a><font size="3"> after selecting a cell.</font></li> <li>Do <u>not</u> use the <a href="#EnterAsm"><strong>F1:Progress Note</strong></a> function on the <strong>MD Assess</strong> form.</li> <li>Do <u>not</u> use the <a href="#EnterAsm"><strong>F11:Chart Now</strong></a> function on the <strong>MD Assess</strong> form.</li> <li><a href="#Formatting">Format</a> the <em>assessment notes</em> properly with <ol> <li>a <u>hard return and a tab</u> at the bottom of each cell, and </li> <li>a <u>hard return</u> at the top of each cell that starts with a list</li> </ol> </li> <li>Primary service <a href="#Co-Signatures">attendings</a> should write their <em>assessment notes</em> in the same time column as the resident note to effectively co-sign those notes.</li> <li>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.</li> </ul> <p><a name="Feedback"><font size="5">Feedback</font></a><font size="5"> </font><a href="#PageTop"><font size="5"><img src="../../images/gotop.gif" alt="Go to top of page" border="0" width="16" height="16"></font></a></p> <p>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 <a href="mailto:spon@mail.med.cornell.edu">Steven Pon</a>.</p> <p> </p> <p><em>April 28, 2000 01:45 PM</em></p>  </body>