cchhs powernote participant guide

Cook County Health and Hospitals System

PowerNote

Participant Guide

PowerNote

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide Effective date: Oct.18, 2010 Version 1 Tracking Number: [enter tracking number] ©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express written consent of Cerner.

TableofContents Overview.......................................................................................................................................................1

Objectives.....................................................................................................................................................2

Key Points ....................................................................................................................................................3

Creating Notes..............................................................................................................................................4Toolbar Icons ...........................................................................................................................................5Point and Click .........................................................................................................................................7Links .......................................................................................................................................................10Free Text Documentation.......................................................................................................................11Auto Text Entry ......................................................................................................................................13Comments ..............................................................................................................................................15Create a New Note from an Existing Note .............................................................................................16

Saving/Signing Notes .................................................................................................................................17

Modifying Notes..........................................................................................................................................20Deletions ................................................................................................................................................22

Filtering Unsigned Notes ............................................................................................................................23

Searching for Specific Notes ......................................................................................................................24

Viewing the Audit Trail ................................................................................................................................25

Images........................................................................................................................................................26Inserting an Image .................................................................................................................................26Using Image Drawing Tools ...................................................................................................................27Editing an Image ....................................................................................................................................29Deleting an Image ..................................................................................................................................29

Macros........................................................................................................................................................30Creating a Personal Macro ....................................................................................................................30

Macros........................................................................................................................................................31Using a Personal Macro .........................................................................................................................32Editing a Personal Macro .......................................................................................................................33Deleting a Personal Macro .....................................................................................................................34

Precompleted Notes ...................................................................................................................................35Creating a Personal Precompleted Note................................................................................................35

Precompleted Notes ...................................................................................................................................36Using a Personal or Shared Precompleted Note ...................................................................................36Editing a Personal Precompleted Note ..................................................................................................37Deleting a Personal Precompleted Note ................................................................................................37

Favorites.....................................................................................................................................................38Adding Favorites ....................................................................................................................................38Accessing Favorites ...............................................................................................................................38Deleting Favorites ..................................................................................................................................38

Preferences ................................................................................................................................................39Personal Document Types List ..............................................................................................................39

Glossary .....................................................................................................................................................42

Icons ...........................................................................................................................................................43

Owner: Cerner Learning Services Cook County Health and Hospitals Systems PowerNote Participant Guide Effective date: Oct. 18, 2010 Version 1 Tracking Number: [enter tracking number] ©Cerner Corporation. All rights reserved. This document contains confidential information which may not be reproduced or transmitted without the express written consent of Cerner.

Page 1 of 45

Overview

This course introduces basic concepts for creating a PowerNote. A PowerNote is a template created for specific documentation needs. These templates allow the user to create a note by selecting responses from lists of choices, adding comments where needed, or pulling in information such as allergies, medications, and results. Physicians may use a PowerNote to document visit information. The PowerNote section of a patient’s chart will display signed PowerNotes, signed Clinical Notes and text-rendered PowerForms.


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Objectives

When you complete this course, you will be able to: • Create and save a new PowerNote document • Correct a signed document • Modify a signed document • Delete an unsigned document • Create and use a precompleted PowerNote. • Delete a precompleted PowerNote • Save a PowerNote template as a favorite • Locate and sign unsigned documents • Create a personal documentation type list


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KeyPoints

1. Signed PowerNotes can NOT be deleted.

2. It is important to select the correct document TYPE prior to saving a PowerNote. Documents saved with the wrong document type will be stored in the wrong folder and may be difficult to locate.

3. Do NOT enter anything in the TITLE field. The correct information will automatically

default into this field. If it is replaced with free text, it may be difficult to locate.

4. When given a choice, always select the *2G PowerNote type. This is the latest PowerNote version CCHHS will be using.

5. Always search for, and sign, your unsigned notes at the end of the day.


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CreatingNotes

Cerner Millennium has a PowerNote feature that can be accessed from PowerChart or FirstNet. The PowerNote feature allows documentation of patient’s visits. Completed PowerNotes may also be located in the Clinic/Hospital Flowsheets and the Clinical Notes section of the patient’s chart. To add a new PowerNote: 1. In PowerChart, open the patient’s chart and verify the right encounter has been

selected. Change the encounter if necessary as documentation must be done on the correct encounter.

2. Using the Menu, click on the Documentation – PowerNotes option.

Creating Notes

Note List Most recently displayed note

Page Navigation

Note Navigation

PowerNote Toolbar


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ToolbarIcons

Common toolbar icons that will be used in PowerNote are described as follows Note! Dithered icons (gray in color) are not available. When a new PowerNote is opened, the following tabs are used to locate the correct template:

Add a new PowerNote

Forward a note

View an image

linked to a note

Electronically sign a note

Make changes to

a note

Search all available templates,

Search all saved and/or signed notes in this patient’s chart.

Search all previously saved partially completed notes to reuse on other patients.

Search for available templates organized by category.

Display notes most recently created by the logged on user.

Note templates that have been selected as favorites for quicker access.

View a note’s audit trail

Display the preview pane


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Creating Notes 1. Click the icon on the PowerNotes toolbar. 2. In the new note window, select the correct document Type. This field is yellow, indicating it

is a required element. It is important to select the correct document type before opening a PowerNote template.

3. Change the date/time if necessary.

Note! Do NOT enter text in the Title: field. This field will automatically default from the PowerNote template selection. If text is entered in this field, it will affect where the note will be saved and may make it difficult to find the note.

4. Select the corresponding tab to search for the correct PowerNote template. 5. If necessary, change the filter options. 6. Select the template. 7. Click the OK button or double-click on the template to open a new PowerNote.

2 3

4

5

6

7

1


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Creating Notes

The PowerNote template will open in structure view. To display the template in full screen view, click on the Full Screen Mode icon on the Documentation toolbar. To exit this view, click on the icon in the upper right corner of the screen.

PointandClick1. The Auto Populate Document will display. This functionality provides the ability to

automatically add patient information to your PowerNote, based on the content version of the particular note selected. Select or deselect the items applicable to the PowerNote and patient.

2. Click OK.


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3. In the navigator on the left, single-click on the paragraph to display the options in the

workspace on the right.

Hides the structure of a paragraph including sentences and terms.

Displays the structure of a paragraph including the sentences and terms.

expanded collapsed

Blue Chevrons indicate a sentence can be expanded to show additional terms or collapsed to expose only the common terms.

Selected term will be circled with bold text.

Negated term will appear with a slash mark.

The + sign indicates here are additional terms that can be selected to further describe the term.

=== Indicates a term where a number will need to be entered.

Launches a box that allows for freetext to be entered into the note.

Launches a provider search window.

An asterisk indicates the term and its associated terms are set to repeat when selected.

Insert Image icon found on the PowerNote toolbar.

4. In the workspace on the right, single-click on the appropriate sentences and terms to

select. Selected options will display circled with bolded text. • To delete a selection made in error right-click on the item and select Clear • To notate a pertinent negative, click on a term a second time. You can also right-

click on the item and select Negate – the item will appear with a slash through it. Not all items can be negated.

Workspace

Paragraph

Terms

Navigator

Sentences

Asterisk indicates 2G note


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Creating Notes

Note! Required paragraphs or sentences will be highlighted in yellow. All required items must be completed before the note can be signed.

5. To preview the note before signing it, click the Note View icon above the scroll bar on

the right. Click the Template View icon to close this view. Term Selection Mouse Action Select a Term Single Click Negate a Term Double-Click Clear a Negated Term Single Click


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Creating Notes

Links Links to import patient information may be available in some PowerNote templates. Examples of information that can be imported using links are: allergies, current medications, lab results, vital signs, etc. To use a link: 1. Point and single-click on the sentence that starts with Include… 2. In the example below, the Include allergy profile option is used which opens the Allergy

Profile section of the patient’s chart.


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Enter your free text here.

Creating Notes

FreeTextDocumentation Free text entries may be added to any section of a note using the OTHER option. To add free text in the OTHER field: 1. Right-click on OTHER and select

Open. 2. Type the information. 3. Click the OK button to save the

information and close the window. The new information will display as a selection. Note! Do NOT double-click on the free text entry after closing the window. This will delete the entry. If this happens, from the Menu bar, click Edit and then Undo.

Example of “OTHER” option for free text.

Example of “OTHER” option for free text.


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Creating Notes To modify free text entries in the OTHER field: 1. Right-click on the entry and select Open. 2. Make any necessary changes. 3. Click the OK button to save the information and close the window. To delete free text entries added using the OTHER field: 1. Right-click on the entry and select Clear. Single-Click = Open OTHER Double-Click = Delete OTHER Right-Click = Menu > Clear As notes are being created, a check mark appears to the left of each section in the navigator indicating documentation is present. A yellow highlight indicates the current section that is being displayed.


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Creating Notes AutoTextEntry

Auto Text entries allow for freetext to be saved and inserted into a note, saving time when entering redundant text or large amounts of text. Auto Text is created, managed and inserted in areas of the note that allow for free-texting - the white space found after the note heading or before and after text within the textual rendering of the note. Create an Auto Text Entry 1. Click in the area of the note that allows for free text. 2. Click the Manage Auto Text button on the toolbar.

3. Click the Add Text… button.

4. Enter the text the Formatted Text Entry dialog window.

5. Click OK.

6. Enter an abbreviation and description in the Abbreviation and Description boxes.

Tip: Since Auto text is available within any section that allows free-text such as an OTHER/WHAT box or free-text area within the note; the tip is to utilize "ZZ" or a special character such as a period (.) or asterisk (*) in front of your auto text. This will help in eliminating your auto text to not pop up continuously as zz is not a common letter used. 7. Click Create.

8. The abbreviation and the description will display as an available phrase. 9. Click Close. Insert an Auto Text Entry 1. Click in the area of the note that allows for free text. 2. Enter the abbreviation of your auto text. A list of abbreviations will appear.

Place the mouse pointer over the entry will display the description of the Auto Text.


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Creating Notes 3. Double click on the entry or press ENTER to insert into the note. The special characters are

replaced with the Auto Text.


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Creating Notes

CommentsComments may be added to a selected terms. To add a comment: 1. Right-click on the selected term. 2. Select Comment. 3. Type the text of the comment in the corresponding window. 4. Click the OK button. 5. The comment displays in (parenthesis) to the right of the selected term. To modify a comment: 1. Right-click on the comment in (parenthesis). 2. Make the necessary changes in the corresponding window. 3. Click the OK button. To delete a comment: 1. Right-click on the comment in (parenthesis). 2. Delete the comment from the corresponding window. 3. Click the OK button. 4. The comment is now deleted and only the term is left as a selected item.


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Creating Notes

CreateaNewNotefromanExistingNote There may be times when it is beneficial to copy forward the contents of a previous PowerNote into a new one. For example, a patient being seen for their annual general medical exam when little has changed from the previous year. Copy forward the old note into a new one and then review and change documentation as needed.

To get started: click the button. 1. Select the Existing tab. 2. Change the filters as needed. 3. Single-click on the correct note from the displayed list. 4. Select the Copy to new note option. 5. Click the OK button. 6. Review and change content as necessary.

1

2

3

4

5


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Saving/SigningNotes

Once a note is complete there are four options available: To sign a note: 1. Click the Sign button. 2. In the Sign Note window, verify the

document Type: field is correct. 3. Change the date/time if necessary. 4. Click the OK button. 5. Refresh when prompted. 6. The note will display in text-rendered

format. Note! Do NOT sign PowerNotes in full screen mode as this will result in PowerChart spontaneously closing.

Deletes note without saving

changes

Saves note and leaves it

displayed

Saves and closes the note

Signs and saves the note

Make sure this is correct!


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Saving/Signing Notes

To forward a note for co-signature: 1. Click the Sign button. 2. In the Sign Note window, verify the

document Type: field is correct. 3. Change the date/time if necessary. 4. Select Request Endosement. 5. Click in the field under the Endorser

column and type in the name of the appropriate Provider.

6. Click in the field under the Type

column and select Sign. 7. Click in the field under Due By column and assign a due date of necessary. 8. Click in the field under the Comment column and type in a comment if necessary. 9. Click the OK button. The completed PowerNote will be forwarded to the designated Provider’s Inbox.


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Saving/Signing Notes

To save a note: 1. Click the Save button to save the note and leave it displayed. ~ OR~ 2. Click the Save & Close button to save the note and close it. To delete a note: 1. Click the Cancel button. 2. Select Discard Changes when prompted.

Signing vs. Saving Signing Saving

Notes that have been electronically signed display in the patient’s chart with a status of Auth (Verified).

Notes that have been saved but not electronically signed display in the patient’s chart with a status of Active.

Signed notes are viewable immediately. Saved notes are viewable only in PowerNote via the Existing tab.


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ModifyingNotes

To modify unsigned saved notes:

1. To find unsigned saved notes in PowerNote, click on the icon on the PowerNote toolbar.

2. Click the Existing tab. 3. Select the Unsigned notes only option. Authors searching for their own unsigned notes

may also select the My notes only option. Change the encounter selection if necessary. 4. Double-click on the unsigned note from the displayed list. Unsigned notes have a status of

Active. Users who attempt to open unsigned notes they are not the author of will receive the following prompt: 5. Make the necessary changes to the note. 6. Click the Sign button when all changes are complete. 7. Select Yes when prompted to refresh.


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Modifying Notes For notes that have already been signed, PowerNotes contains a modify feature that utilizes a strike through function along with an addendum. Signed notes may be modified multiple times. To modify signed notes: 1. In PowerNote, select the note from the displayed list.

2. Click the icon on the PowerNote toolbar. 3. You are presented with the option to either Modify or Correct the document.

Modify Document – Allows the user to add an addendum to the note. This option does not allow changes from within the note. When signed, the note status will reflect, Document Has Been Updated And Contains Addenda. Correct Document – Allows changes to made from within the note. This option will display

what the corrections were made and by whom. Click the Display Contributor View icon to view the changes.

4. Make the appropriate corrections and click Sign 5. Authorize your signature by enter your password and click OK. 6. Select Yes when prompted to refresh the list.


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Modifying Notes

DeletionsNotes that have been saved but not signed may be deleted. Important Note! Notes that have been signed cannot be deleted. However, you can mark your own signed note as “In Error”.

1. To find unsigned saved notes in PowerNote, click the icon on the PowerNote toolbar.

2. Click the Existing tab. 3. Select the Unsigned notes only AND My notes only options. Change the encounter

selection if necessary. 4. Select the unsigned note from the displayed list. Unsigned notes have a status of Active. 5. Click on the Delete button. 6. Click Yes to continue with note deletion. 7. Click Yes when prompted to refresh. Note! Be careful not to delete another author’s unsigned saved note. If another author’s note is opened in error, the following prompt will display:


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FilteringUnsignedNotes

If notes have been saved in PowerNote but not signed, there is a way to locate all unsigned notes.

1. In PowerNote, click the icon. 2. Select the Existing tab. 3. Select Unsigned notes only AND My notes to display all unsigned notes authored by the

logged on user. Change the encounter selection if necessary. 4. Select the unsigned note from the displayed list. Unsigned notes have a status of Active. 5. Click the OK button to open the note or double-click on the note to open. 6. Review and edit as needed. Make sure the document Type is correct. 7. Click the Sign button when finished. 8. If the document Type is missing, a prompt will display. Select the correct document Type if

prompted 9. Select Yes when prompted to refresh.


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SearchingforSpecificNotes

PowerNotes may be filtered to find specific notes as needed. 1. In the PowerNote List tab, click the Display drop down. The default is set to display All

text-rendered notes. 2. Select the Only option.

3. A new field displays, click the drop down to select another level of options. 4. Another new field displays, select the third drop down to narrow the search further.


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ViewingtheAuditTrail

If it becomes necessary to view the audit trail of a corrected or modified note, this can be done through PowerNote. 1. In PowerNote, select the patient’s note from the displayed list. 2. Hover the cursor over the solid grey line below the bottom scrollbar until it displays as a

two-sided arrow. 3. Click and drag the drag the two-sided arrow toward the top of the note to size the new

viewing pane.

Selected note

Audit trail


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Images

InsertinganImage

PowerNote allows users to insert images. 1. In the PowerNote template, click on the paragraph or sentence where the image needs to

be inserted.

2. Click on the Contributor View icon. 3. Click the correct location for the image inside the note.

4. Click on the Insert Image icon to open the Drawing Box.

5. Inside the Drawing Box, click the Folder icon to locate the image. 6. Find and open the corresponding folder that contains the correct image. 7. Select the image and click on the Open button. 8. The image will display in a drawing box. In the drawing box, enter an Image Title. The title

will display along with the image in the note. Use the drawing tools to add detail to the image as needed (see the next page for directions on using this functionality).

9. Click the OK button to view the selected image in the note.


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Images

UsingImageDrawingTools PowerNote drawing tools offer a variety of options to assist with adding detail to inserted images.

A. Insert • Open Image File • Capture Image

with Camera

B. Drawing Tools • Draw • Annotate • Zoom • Crop • Ellipse • Line • Rectangle

C. Enhance • Color • Resize • Rotate Left • Rotate Right

D. Edit

• Undo • Redo

E. Size • Reset Zoom • Size to fit Screen

A B C D E


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Images To use the drawing tools: 1. In the Drawing Box, click on any one of the drawing shapes. 2. Change the Brush Width if needed. 3. Click on the Color Chooser icon to change the color of the drawing shape if needed. 4. Click and drag the cursor over any part of the image to make the necessary shape.

Note! The Ellipse Tool takes a little finessing to get the shape right. • Click and drag the ellipse on the image. • When the ellipse is the right length, release the left mouse button. • Move the mouse to move the cursor and shape the ellipse. • Click the left mouse button again to save the shape.

5. To clear the image of any drawings to start over, click the Clear Drawing button. 6. Click the OK button when finished. To use the annotation tool:

1. In the Drawing Box, click the Text Tool icon. 2. Click on the Color Chooser icon to change the color of the drawing shape if needed. 3. Click and drag the cursor over any area around the image to size the text box. 4. Type the necessary text in the text box. The text color will appear black until finished. 5. When finished making the notation in the text box, left-click to display the text in the image.

The text color will display correctly if the Color Chooser was selected prior. 7. To clear the image of any annotations to start over, click the Clear Drawing button. 6. Click the OK button when finished.

Drawings

Annotations


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Images The completed image will display in the PowerNote document like the example below.

EditinganImage

1. In PowerNote, click the Contributor View icon. 2. Right-click on the image. 3. Select Open. 4. Add further details. 5. Click the OK button. Note! It is not possible to edit any detail that is already present on the image.

DeletinganImage

1. In PowerNote, click the Contributor View icon. 2. Right-click on the image. 3. Select Clear.


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Macros

A macro is a helpful tool used for documenting repetitive information across patient charts. When certain sentences, and /or paragraphs are used frequently, a macro can be used to automatically inserts terms in the note. There are two types of macros in PowerNote: 1. A shared macro is available for multiple people to use. 2. A personal macro is saved at the individual level and can only be used by the person who

created it.

CreatingaPersonalMacroBest practice is to create macros at the paragraph level. Macros created at the paragraph level can be utilized within any PowerNote that has that same paragraph level available. To create a personal macro: 1. Open a patient’s chart. It is necessary to use an actual patient to create the macro.

Nothing will be saved to the patient’s chart. 2. Select the PowerNote option form the Menu.

3. Click the icon. 4. Select the appropriate note template. 5. Navigate to the paragraph where the macro is needed. 6. Complete the section of the note as you normally do; each term that is selected will be

saved in the marco If OTHER is used, type the required text in the box. 7. After completing, right-click on the paragraph or

sentence and select Save Macro As. 8. In the Save As window, enter a name for the macro

in the Title: field.

It is the user preference to determine the naming convention for the marco.

The macro can be saved as a public or shared macro. If so, it is visible to other providers.

bh010671 � 10/5/10 1:20 PMDeleted: text


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Macros

9. Click the Create New button when finished. A blue M now appears on the note identifying that a Macro is available 10. Click the Cancel button to exit the PowerNote or complete the note. 11. If you Cancel the note, click the Discard Changes button when prompted.


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Macros

UsingaPersonalMacro To use a personal or shared macro: 1. Open a patient’s chart. 2. Select the PowerNote option form the Menu.

3. Click the icon. 4. Select the appropriate note template. 5. Navigate to the paragraph where the macro is needed. 6. Right-click on the (blue) M and select the appropriate macro. If the necessary macro is not

displayed, select the More option to view a complete list of macros.

7. Select the appropriate macro. Once the macro is selected, the designated choices and text

will pre-populate automatically.


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Macros

EditingaPersonalMacro

To edit a personal macro: 1. Open a patient’s chart. It is necessary to use an actual patient to delete the macro.


3. Click the icon. 4. Select the appropriate note template. 5. Navigate to the paragraph where the macro is saved. 6. Make the necessary changes the information in the paragraph. 7. After all changes have been made, right-click on the paragraph text and select Save Macro

As. 8. Select the macro from the list and click the Update button. 9. Click the Cancel button to exit the PowerNote. 10. Click the Discard Changes button when prompted.


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Macros

DeletingaPersonalMacro To delete a personal macro: 1. Open a patient’s chart. It is necessary to use an actual patient to delete the macro.


3. Click the icon. 4. Select the appropriate note template. 5. Navigate to the paragraph where the macro is saved. 6. Right click on the paragraph text and select Save Macro As. 7. In the Save As window, select the personal macro. 8. Click the Delete button. 9. Click the Cancel button to exit the PowerNote. 10. Click the Discard Changes button when prompted.


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PrecompletedNotes

Whether you are a surgeon, specialist in allergy and asthma or a family practitioner, your particular patient encounters may have common characteristics. For example, a family practitioner may see several patients daily with hay fever during the fall months, or the flu during winter months. These types of recurring illnesses result in repetitive data entry when you create encounter notes. In PowerNote you can document such an encounter once and then save it as a precompleted note, which can then be used as a template for future use. Precompleted notes will contain pre-populated sections that are always documented the same. Information in the precompleted note may be changed as necessary to accommodate variations in documentation needs. The intent of the precompleted note is to provide 80% of the needed information so only the remaining 20% requires actual documenting.

CreatingaPersonalPrecompletedNote

1. In PowerNote, click the icon. 2. Select a note template from one of the tabs. 3. Complete the sections of the note with the appropriate information. 4. From the Menu bar, click Documentation. 5. Select the Save as Precompleted Note option.

In the Note title: field enter the name of the precompleted note. 6. Click the Save as New button.


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PrecompletedNotes

UsingaPersonalorSharedPrecompletedNote

1. In PowerNote, click the icon. 2. Select the Precompleted tab. 3. In the Search: field, type in part of the note name. OR 4. In the Restricted display by section, select My notes only to narrow the search. 5. Complete the sections of the note with the appropriate information.


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Precompleted Notes

EditingaPersonalPrecompletedNote

1. In PowerNote, click the icon. 2. Select the Precompleted tab. 3. Select the note. 4. Make the necessary changes to the note. 5. From the Menu, select Documentation. 6. Select Save as Precompleted Note. 7. Click the Click the Update Exisiting.

DeletingaPersonalPrecompletedNote

1. In PowerNote, click the icon. 2. Select the Precompleted tab. 3. Select the note. 4. Click on the Delete button.


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Favorites

PowerNote templates may be added to the Favorites for easier and faster selection when starting a new note on a patient. Maintaining a list of favorites allows frequently-used notes to be located quickly.

AddingFavorites

1. In PowerNote, click the icon. 2. Select the tab where the note template is located. 3. Select the note. 4. Click the Add to Favorites button.

AccessingFavorites

1. In PowerNote, click the icon. 2. Select the Favorites tab.

3. Select the note.

DeletingFavorites

4. In PowerNote, click the icon. 5. Select the Favorites tab. 6. Select the note to be deleted. 7. Click the Remove from Favorites button.


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Preferences

A document type must be selected for all new PowerNotes. Selecting the correct document type determines where the note will be saved in the patient’s chart. This can be changed to narrow the number of choices for faster selection.

PersonalDocumentTypesListBy default, all available document types are displayed. Each user can create a personal list of frequently used document types. A default document type may also be set, however, this is discouraged due to the fact once a note is saved, it cannot be moved to a different folder if it was saved incorrectly. To create a Personal Document Type list:

1. In PowerNote, click icon. 2. From the Menu bar select View and then

Customize. 3. In the Customize window, select the

Document Types tab. 4. Select the Personal Note Type List from the

Default List Type field. 5. In the All Available Document Types

column, select the needed option. 6. Click the single right arrow to move it to the

Personal Document Type List column. 7. Repeat steps 7 and 8 until all needed options have been selected. 8. To remove an option from the Personal Document Type List, select the option and click the

single left arrow to move it back to the All Available Document Types column. 9. Click the Apply button. 10. Click the OK button. 11. Close the patient’s chart and reopen to refresh changes.


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Preferences To use the Personal Note Type List: 1. Open a new PowerNote. 2. In the Type: field, right-click and select Personal Note Type. 3. Make the appropriate selection from the list. To use the All Note Type List: 1. Open a new PowerNote. 2. In the Type: field, right-click to access the All Note Type List. 3. Select the All Note Type List. 4. In the Type: field, click the drop down arrow. 5. Make the appropriate selection from the list.


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Inbox The In-Box is where you will find PoweNotes that have been sent for your signature or review. Med students will be allowed to save a note and will need to forward the note the attending/resident for signature. 1. To access your Inbox, from the PowerChart toolbar, click the In-Box button.

If you don’t see the In-Box button, click the black down arrow and select In-Box.


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Glossary

Term Definition

*2G The newest version of a PowerNote. ALWAYS select this when there is more than one note of the same title displayed.

Contributor View How a PowerNote will display once saved. The individual selections and comments are combined into a more readable note format.

Macro A small selection of documentation that has been saved for future use. Macros are maintained at the level they are created within the PowerNote. Macros are available within any PowerNote that contains the level. Macros can be built up to a paragraph level.

Negate Allows a term to be included in the note as a negative finding. Used for pertinent negatives. Not available for all terms.

Pre-Completed Note A note saved as precompleted has already had results entered and has been saved to use repeatedly when only minor edits are used from patient to patient. Use of pre-completed notes reduces documentation time.

Document Type This will be the “label” for the folder in which the note will be stored.

Paragraphs First level of documentation in a PowerNote

Sentences Second level of documentation in a PowerNote

Terms Third level of documentation in a PowerNote


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Icons

PowerNote Toolbar Icons

Description

Create/Locate a template, favorite, precompleted or existing note

Full screen mode

Save

Submit an unsigned document for signature or review

Sign the displayed document

Forward/Refuse a document for signature or review

Review a document

Display the audit trail (history) of a document

E & M assistant

Modify order details if orders are placed from documentation

Used to make corrections or modifications to a document

Copy

Paste

Dictate using Dragon

View an image linked to a document

Find next structured item

Find/Move between required terms

Document has been marked as an error and cannot be opened

Open preview pane


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Icons

Documentation Icons

Description

Insert canonical sentences into terms

Negate term and deselect all subsidiaries

Set the term to normal and deselect all subsidiaries

Add or view comment associated with term

Make a copy of term and all subsidiaries

View reference information related to term

Not available

Note available

Deselect term and all subsidiaries

Enter a reason for not documenting a required element

Display the insert macro dialogue

Display the save macro dialogue

Relocate the term upwards by one position

Relocate the term downwards by one position