Medication Profile

Power Chart Medication Profile and Problem List Optimization

HIM Committee Meeting

March 25^th, 2011

1.    Control vs. Shift in selecting items to clear from medication profile.

a.     Click Power Orders

b.     Left click on medication that you want to remove (ex. dicloxacillin)

c.     Next press the Ctrl button and hold down while left clicking other medications that you want to remove (ex. naproxen and trazodone)

d.     Then after you have selected all the meds you wish to remove, remove your finger from the Ctrl button, and right click over one of the blue highlighted areas and select Cancel/DC

e.     To select all meds in a row press shift instead of Ctrl (ex. dicloxacillin through trazodone) right click over blue highlighted area and select Cancel/DC

f.     Another method is to select each medication in either Power Chart Office or Power Chart

by right clicking over each medication, then select Cancel/DC

2.    Different Methods for Medication Reconciliation

a.     Open Power Chart, open your patient’s chart, click Medication Profile from the Menu on the left side of the screen, then select Medication Profile at the top of the screen, then Print List --Active Medications

b.     Open Power Chart Office, open your patient’s chart, click Clinic, select Reports, Print Reports…then click Medication List, then click Print 

3.    Macros for medication reconciliation

4.    How to remove problems from problem list

a.     Left click and highlight problem

b.     Right click over highlighted area and select modify problem

c. Next click the *Status drop down box and select either Error or Canceled down box and select either Error or Canceled

PowerNote Updates2

This e-mail is about the view in PowerNotes and primarily applies to those using free text notes.  Since the paragraph structure in the note collapses as the note is entered, the default has been reset to keep all the paragraph structure viewable as the note is entered.  For those entering free text notes, this is not useful and appears to affect the ability to enter free text.

If you are preferentially entering free text notes, see the attached document for instructions to set your view back to where it was.  The steps are simple and will hold for every patient/ every use of PowerChart. If you mostly use templated notes, you may not want to reset the view.

To enter free text into any note, use the 'contributor view' as shown at the end of the handout.  This view allows free text entry and the system response should be better.
Please don't hesitate to let me know if there are ongoing issues and I will try to help you or refer you to someone who can.

Entering Free Text into PowerNotes:

Open a note (it can be any type): this example uses free text note type You may not see any heading at this time:

In the upper left hand corner of the screen, just below the patient’s name, click on ‘View’

In the drop down menu, click on ‘Customize’

The Customize dialog box will pop up, as shown below:

Entering Free Text, contd:

In the Customize Dialog box, click on the ‘More’ tab;  you will see the screen shown below.

On this screen, click on the 4^th box – ‘Render text in Template View’

On the bottom of this box, click Apply, then OK.  You only need to do this once; the changes will remain. 

The header for your note will re-appear.

To type free text into the note, switch to the text view by clicking on the face (see below)—it will say ‘contributor view’ –  on the right upper corner of the note.  This icon shifts between the structured view and the textual view of the note. Typing free text is possible in the text (contributor) view (and response time should be much faster as well).

PowerNote Updates

Leadership has made the decision to improve upon Powernote functionality by removing the <Hide Structure>/<Expand Structure> option at the paragraph level of Powernote templates. This means that all paragraphs (sections of the template) will now be expanded by default, eliminating sentences from being hidden (see below). This also prevents paragraphs from defaulting to a collapsed state when populating previous documentation into your note.

Along with this, the <Use Free Text> option at the paragraph level will no longer be available. Instead, you may now free text comments for paragraphs in the in the “contributor view” while documenting (see below).

This change is effective immediately. Please communicate this to your colleagues/staff and provide me with any feedback, as we are always looking to improvements this application.

BEFORE:

AFTER:

*To free text at the paragraph level, click the “contributor view” icon   in the top right corner of the note. Then on the line below that last piece of documentation within a paragraph, click to insert your cursor and begin typing (ex: click below “referral source” in the example below). To flip back to the structured documentation, click the “template view” icon  in the top right corner of the note.

Rx Writer (Dr. Stabile)

After the printer has been selected and the order signed, the printer will be saved as your default printer only for Rx Writer. 

Residents

For now in Clinical Notes, the residents need to “submit” versus “save and close.”  They may do several iterations of “submit” to edit.

For PowerNotes, the residents need to “sign” and select the attending to route the note to.  Until we identify the fix, using the “save” button is deleting the previously charted note and saving only the current addendum notes.

"Note Type" in PowerNote

1.       Open a Powernote

2.       Click VIEW on the top toolbar, then CUSTOMIZE

3.       Select the DOCUMENT TYPES tab

4.       In the “Default note type” drop down, select NONE

5.       The “display last document type used as default” box becomes active

6.       Check this box

7.       Click APPLY

Canonical Sentences (Dr. Barker)

Another way to add items to a note is to insert options to specific paragraphs.  PowerNotes are divided up into “Paragraphs” and “Sentences”.  The Paragraphs such as “Visit Information”, “Chief Complaint”, and “History of the Present Illness”.  Paragraphs are separated by a clear space (that you can free text into).  Within each paragraph are a number of “sentences” separated by horizontal lines.  Below is the paragraph Visit Information and its five component sentences:

If you click on a paragraph’s name – an icon in the upper left appears.  You can also get this icon by clicking on a paragraph name in the light blue navigation pane on the left side.  Click the icon.

 

Close up of this icon:  

I am in the Physical Examination Paragraph, if you click it this “Insert Sentence” popup opens: 

These are sort of “developers tools” that were not used to build a particular note, but are available if you want to insert them.  They are called “Canonical Sentences”. Let’s choose the one that says “Feet” and click it – it will highlight in red and a check mark will appear.  Then click the single arrow at the bottom of the box (this is a scroll down one line).  Click the “Lines and Tubes” line it will highlight in red and a check mark will appear – the check by “Feet” will remain.  Now click OK.  The double arrows scrolls the choices by one whole page ~12 choices.  

Now what you have is the original Physical Examination Section with the two extra sentences “Lines and Tubes” near the top and “Feet” added near the bottom.

 

If we click on the chevrons to expand the Feet sentence content you get this which would allow you to document a lot of foot findings. 

 

Keep in mind that each paragraph has its own menu of canonical sentences – eventually you will get familiar with what is available.  Here for example is the second page of choices under the “Review and Management” paragraph.  When a canonical sentence has a chevron (right pointing arrowhead) as “Sleep studies” does here it means it has sub-sentences available.

  

You can, if you want insert more than one of these into the note. 

  

At this point you may be saying that this is an impossible amount of stuff to try to remember.  The logical thing to do is explore this as a tool – pick out the things that may be useful to you in your role and insert them and save it as a pre-completed note.  In this example if your work included reading sleep studies you would insert these sentences and then save the expanded template as a Pre-completed Note called maybe “Sleep studies”. 

These are just tools available to you.   You don’t have to use them.  But the best and swiftest craftsmen make the best use of the available tools.  

Dealing with Resident Notes- Comment Dr. Judy Neafsey

Jay, Thanks for the description for resident supervision.  I will pass it on to a few people and I agree if others find a better way--let everyone know.  My only question and I will also try tomorrow when I am in clinic--I didn't know you could strike through parts of the resident note already signed.   I thought you could only add the addendum.  Have you done it?  Also, if you just go to the patient chart in your list and open it I believe you can add the addendum even if they don't "endorse" it to you. This may mean more searching on the attending's part by sticker or patient list but still an option if not endorsed.   If this works well I would share it with all the teaching clinics and the specialists. It is possible to save an autotext of a couple different general attestations as well to put in the addendum. Judy

Dealing with Resident Notes (Dr. Jay H. Mayefsky)

Once a resident signs a note, it cannot be edited any longer (i.e. fields clicked on or text entered into the text of the note). All you can do is modify the note. This allows you to free type an addendum at the end of the note and to strike through parts of the resident note you want deleted.

 So this is the way I recommend to deal with residents:

1.       After the resident finishes seeing the patient, before he presents, he needs to “save and close” his note.

2.       The resident then comes to the attending to present.

3.       The resident should log on to PowerChart at the attending’s terminal (as well as the terminal in his exam room). The reason for this is so that the note may be edited if necessary and/or signed by the resident at the time of the presentation. If the note is opened in the attending’s version of PowerChart, the attending will become the author of the note and the resident’s name will be deleted.

4.       When the attending agrees that the note is complete the resident can sign the note. Upon signing, the resident in prompted for an “endorser”. He should type in or select the name of the attending to whom he presented. The note is then automatically sent to the attending’s “inbox” in PowerChart.

5.       The attending clicks on the inbox icon, double clicks on the note marked “pending”, and opens it.

6.       The attending clicks on the “modify” icon, adds the attending note, and then signs the note.

7.       The note is still attributed to the resident and contains the attending’s note and electronic signature as an addendum.

If you find a better way let everybody know.

Jay H. Mayefsky, M.D., M.P.H.

Professor of Pediatrics and Preventive and Family Medicine

Inserting one PowerNote template into another (Dr. Barker)

.It is possible to utilize one PowerNote template inside another – typically this occurs because you are using one of your customized PreCompleted notes and you realize that the patient has a specific complaint that could be more easily documented using an available PowerNote designed for that complaint.  Here is how you insert one note into another.

Here I have opened the HIV Outpatient note and started to work with it when I realize that this patient really has abdominal pain as their primary problem.

Go to “Documentation” click on it and choose “Encounter Pathway" 

In the resulting Popup I type Abdominal Pain and I pick the middle one, and click OK in the right lower corner. 

 

Now what I get is a combination of the note type I started with and most of the components of the abdominal pain note inserted into my original note.   Many of these are very useful for documenting this specific type of complaint. 

 

 

PowerNote Guide (Cerner)

PowerNote Guide (Cerner)

Diagnosis and Plan (Repeat) – huh? (Dr. Barker)

 

Down at the bottom of most PowerNotes is the least understood section of all – and probably the most important.

 

Why do we need to break up diagnoses this way?  It has to do with Medicare.  Under Medicare rules each order for an outpatient has to be tied to a specific diagnosis.  This design is set up to encourage us make clear why we ordered something.  Once you figure it out – it can be fairly easy. 

First the (Repeat) – this is here so you can add more sections if you need them – for a patient that has more than one diagnosis.  For many notes that are specific to a disease there is already one paragraph at the top that lists a diagnosis or several diagnoses possibly relevant to the complaint.  Then you can repeat as many paragraphs as you need.  To get a new Paragraph – right click the word (Repeat) and drag down and click on Repeat in the drop down. 

 

The other key piece of info to have here is that benign looking first statement

"OTHER DIAGNOSIS" – click it. 

You will get this:

Conceptually this box had two parts – the bottom part is the Problem List and the top part is the Diagnosis list.  What it wants you to do is select those problems that you are addressing on this visit, put them in the top Diagnosis box, and then say include them in separate paragraphs of the note.   There are several ways you can do this.  1. you can click on a problem in the bottom box and holding the left mouse button down drag it to the upper box.   2. you can right click on a problem in the lower box and click “Add to diagnosis.    

 

You can also modify your problem list from the bottom box by right-clicking the bottom box and clicking Add Problem. 

This takes you here where you can look up new problems and add them to the problem list and if you want the diagnosis list at the same time.  

Now to address this diagnosis you click on just one diagnosis – for this paragraph and then click on the “Include” button. 

You will get this: 

Now you can click off whether it is getting better or worse – another billing thing, and what you intend to do about it. 

The other thing in here is the spot that says PowerOrders.  

If you click on this you open the Orders window – in 2011 we will start using this to prescribe meds for outpatients and hopefully place our lab orders electronically.  

And anything I order this way gets tied to that diagnosis to keep Medicare happy and is documented as part of my plan under that diagnosis 

If you are tackling additional diagnoses, click the next one in the top box and include it in another paragraph and repeat until you have documented all the ones you addressed.  Remember the ability to re-use and Existing note?  It could allow you to do this once and benefit on a bunch of complex subsequent visits.

So – OTHER DIAGNOSES lets you hunt through Problem list for things you want to manage on this visit (or you can add new ones to your problem list and diagnosis list).  Generally you want to put one Diagnosis per paragraph – (Repeat) ing as many extra paragraphs as you need.  This is a fairly easy way to document how you are addressing each problem.  Soon you will be able to order meds and labs for outpatients through this – as you already can for inpatients – invoking PowerOrders from a PowerNote lets you go right back to your note as soon as you are finished ordering.

One thing to keep in mind – Medicare does not expect you to be perfectly correct about your diagnoses.  You can reinforce this by clicking on some of the choices in the Add Problem box like “possible” or “differential”, or using the Comments box on the right side.   For example Medicare will not pay for a PSA as a screening test but if you say the patient has possible Prostate CA as a differential for his BPH symptoms they will.