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Thursday, December 2, 2010

Pre-Completed Note (Dr. Barker)


PowerNotes allow you to take a PowerNote and use it as a template for your typical patient visits.  So lets say I want to have an outpatient note for seeing patients with osteomyelitis in I.D. Clinic.

I start off by changing Type to Infectious Diseases Outpt, I want to see if there is a note type that can be useful so using the encounter pathway I type “osteo” and I find out there is a pediatric osteomyelitis note. 



 

I can go through this entire note filling in all the bits that are likely to be correct – like most of these come to clinic from nursing homes where they are getting IV antibiotics (using my AutoText).

 





Once I have it completed it I go up to the “Documentation” tab at the top – click on it and then select “Save As Precompleted Note” 




 




Next screen asks me to name it – lets call it “Osteo in I.D. Clinic”  And click on the “save as new” button. 

 







These new “Precompleted Notes” are accessible under your tab of the same name when you go to add a note. 








So what does this get you – you could create a whole bunch of personalized templates where large sections of the note can be completed ahead of time.  For example most of us do the same elements of physical exam for each asymptomatic outpatient we see you can check off all the physical exam elements as normal and then just alter any you find are abnormal.  Typical visit is one such note for me – this is the PE section.  Anything I skip I just uncheck, anything abnormal I just change – but all the normals are all ready checked off. 









You can do the same thing for lots of different common conditions, and procedure notes.  This can be a big time saver – just remember not to use it to document things you did not do. 

So if you are making a Precompleted note you want it to be somewhat generic, but specific for your exam, your patient education, etc. 

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