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. 

 

Using an Existing Note (Dr. Barker)

Even better than using a PreCompleted note is re-using a prior note on this patient as the basis for the current note.  All the diagnosis stuff at the bottom is already there and frequently PE just needs updating. 

The second tab when you Add a note is “Existing”, click and you will see prior PowerNotes on this patient.  Using the check boxes you can filter the list when it gets long by looking only at your notes.   Generally you want to have “All encounters” checked for outpatients, “Current encounter” might make sense for inpatients. 

 

  Pick the note you want to use and then click OK.

 

  When you import a note this way it frequently comes into view in the “Display Note View”.  To change it so you can work on it click on the button in the upper right that says “Template View."

Couple of things to be mindful of – it has a tendency to include the vital signs of the original note and the current visit.  Click on and then “clear” the old ones if you want.   You may need to update the medication list – and sometimes it imports things like meds, allergies, and dx twice (old note and new AutoPopulate) doubleclick or right click and clear to get rid of older one. 

 You will need to add any new diagnoses and delete any you are not addressing at this visit in the diagnosis and management section.  Also remember to clear any physical, lab, or consult info that is not longer relevant.  But for many routine outpatient visits, and probably many inpatient days the last note might be a good place to start from for today’s note.