Frequently Asked Questions
- What will change when electronic documentation goes live?
- What about the paper consult form?
- Will Doctors and Nurses use the same PowerChart documentation method?
- What PowerChart tools will make it easy for me to write notes with sufficient detail?
- How will my colleagues see what I have written?
- I am accustomed to seeing sticky notes and other communication papers in the chart, what will happen now?
- How can I draw on a Progress Note?
- Will all paper be extinguished from the record?
- Where do I place prescriptions and other documents that will remain on paper for the patient’s use at discharge?
- What is the difference between signing and saving a note?
- How do I edit or modify a note?
- My note needs to be cosigned, how does the preceptor or responsible physician do this?
- I am a medical student, what do I do?
- I am a Resident, do my notes need to be cosigned? How should this be done?
- I am an Attending physician or resident/medical student preceptor. How can I review and sign my trainee’s note?
- How will Document Performance Improvement staff, or others, ask questions about a diagnosis or other topic?
- How can I learn to create Dragon voice recognition macros? How can I become a better Dragon user?
- How can I improve Dragon’s voice recognition accuracy?
- Can I use the hospital “network version” of Dragon from my home or office?
- I use Dragon in my office. How can I bring my commands to ChristianaCare without needing to redo this work?
- How can I build my own personalized “quick text” (aka “dot text” or .text) keyboard shortcuts?
- I really like the new “quick orders” that is part of the documentation process. Can I use this when I’m not writing a note?
- How do I make sure that the diagnoses in my note are properly sequenced so that the important items come first?
- Why can’t I use the PowerChart documentation tool for admission, operative report, and discharge documentation?
- How can I be sure that a computer will be available when I need one?
- What can I do if there are no available computers when I need one?
- How can I get a printed copy of my note?
- How can I communicate something about a note, or about the patient, to my colleague?
- Why does the electronic documentation system look different from the rest of PowerChart?
- My colleague has created many wonderful Dragon templates and keyboard “quick text”, is there some way for me to use these?
- How can I use “quick order” favorites? Can these be shared among members of my department?
- What is the status of PowerChart on an iPad or other mobile device?
- How does PowerChart documentation relate to Centricity?
- What am I hearing about DHIN information becoming part of PowerChart?
- I have heard that PowerChart has the capability to do a Google-like search for information that has been documented or ordered for a patient, how does this work?
- I find the discharge process to be very cumbersome and time consuming. Are there plans to address this?
- What’s new in the ED with respect to electronic documentation?
- Will Women’s and Children’s areas use the same PowerChart tools and processes as the rest of the hospital?
- What about electronic documentation and ordering processes for the NICU?
- The Surgicenters still use paper. What are the plans to bring these areas live on PowerChart orders and documentation?
- Will my progress notes be sent to DHIN?
- My patients are referred by community physicians who don’t admit to the hospital. Can these doctors follow their patients electronically by reading the progress notes?
- I have heard that it’s possible to pull PowerChart information automatically into my progress note. How can I do this? How do I know what’s available for automatic insertion?
- If I pull information into my note, can I remove it before I sign the note?
- How can I “tag” information to be inserted into my note?
- How can I find documents that others have written? What documents are supposed to be included in the PowerChart “documents” section?
- What do the diagnostic result order statuses mean?
- How do I communicate information to another provider (inbox, sticky note, progress note)?
- I know how to use Dragon because I use it in the office. Do I need to come to training? Is there a quick video for me to learn what I need to know so that I can skip training?
- How do I sign up for training?
- How do I get help if I need it?
- How can I see my patients’ telemetry strips on the floors?
- How can I see my patients’ EKGs?
- My patients have paper forms that are completed during a procedure (e.g. vascular procedure form). How will I have immediate access to this form before the document is scanned into PowerChart?
- My patient is being transferred from an eCare ICU. How can I see the transfer document?
Most paper documentation for physicians will become electronic. Paper will no longer be used for progress notes, or for documentation that is added to the chart such as critical lab results, communication documents, nurses’ progress notes, bedside procedure notes, or quick notes pending dictated documentation. Admission H&P, Operative Procedure Notes, and Consults will continue to be dictated.
Consults should be dictated for transcription. If a chart update is needed, pending the transcribed consultation document, then an electronic progress note should be used. The note’s subject should be “Brief Consultation – [Specialty]”
All electronic progress notes/communication documents will appear in the same document section of the chart. However, providers (physicians, PA, NP) will use an efficient tool called “dynamic documentation” that pulls information in PowerChart into their notes. Nurses and others will use a different tool in PowerChart.
The PowerChart tool called “dynamic documentation” is designed to allow physicians to do their daily work of reviewing results, writing orders, and other activities and then automatically pulling this into the documentation. This tool is designed for documentation to be a by-product of daily work instead of a task in itself. Information that is known to PowerChart can be automatically inserted instead of re-copying or hunting for the information. For example, vital signs, Intake & Output, ABG’s and other labs can be called into the note. Dragon voice recognition and autotext can be customized to easily express common phrases.
Electronic documents, from a variety of care providers including doctors, nurses, and others, will all be collected in the Documents section of PowerChart. This way, a physician can scroll through a list of documents easily reading everything that has been charted since his or her last visit.
Sticky notes in the chart will be replaced by a number of different tools:
- Critical results will be a document. Nurses will be notified of a critical result that requires action, and will communicate this to the provider by a document instead of a critical result form in the chart
- Care providers who need to communicate information to each other will use a communication form that will reside in the same folder as the progress note. It will be seen as the provider reviews new documents since his or her last visit
- Stickers in the chart, e.g. from medical devices, will be scanned into the electronic chart.
Dynamic documentation, in PowerChart, is a new tool that does not yet have drawing capabilities. In order to accommodate the need for line drawings we will provide special paper drawing sheets available from the “Forms on Demand” icon in PowerChart. (Form 23716 – Progress Record – Diagrams & Documentation) The drawing form will have the patient identifier already printed on the paper. Once your drawing is complete, drop it in the bin near the unit clerk, and it will be scanned into PowerChart.
No. Some types of paper are not yet ready to be replaced by an electronic format. Examples of this are telemetry strips, pacemaker interrogation forms, other documents, device stickers, vascular forms, nursing flowsheets etc. Paper that needs review during the hospital course will be scanned into PowerChart. If you have paper documentation that you feel should be included in the patient’s electronic record right away, place it in the STAT SCANNING bin at the nursing station. Documents that simply need to be filed will be stored in the chart folder and will be scanned into Access Anywhere on discharge.
Individual units and programs may have specific practices about this, but it’s always acceptable to place documents such as paper prescriptions in the chart folder for safekeeping until discharge.
A “signed” note cannot be modified by anyone; an addendum can be added. A “saved” note is modifiable only by the author of that note. It is not acceptable for anyone other than the author of the saved note to make changes to that note. If a change is needed to a note that isn’t yet signed the best practice is to use message center to request the change from the note’s author. New with electronic documentation is the ability for everyone, not just the note’s author, to see a “saved” note in PowerChart prior to final sign. Authors of notes that are “saved” should add their name, and d/t to the bottom of the note so that the end of their documentation is clearly visible in case someone adds to their note.
If you would like to modify your note prior to signing it, double clicking on the note will open it for editing. You can also right click on the note in the document list and select modify. If you would like to edit a signed note, select modify, and an addendum to the note will be added at the end. You cannot change a note that has already been signed.
Best practice is to list the name of the responsible signatory physician if you know this in advance. For example: “Cardiology Progress – Dr. Smith” if Dr. Smith is your preceptor.
There are two methods to cosign a note, based on whether the note has been “saved” or final signed:
- For saved notes: open the note and add your comment under the author’s signature. You can then proceed to sign the note, in which case your name, date/time will be automatically added at the time of final signature. If you choose to save the note again, instead of final sign, you should manually add your name, date/time to the bottom of the note so that the end of their documentation is clearly visible in case someone adds to their note.
- For signed notes: open the note; you will see an icon that will allow the preceptor to modify the note. When this icon is selected an addendum will be added beneath the note; the original text cannot be modified. The preceptor can add information after the addendum heading.
Third year medical students should write their notes and save them (not final sign) so that their preceptors can instruct them about the note’s content and recommend revisions that the student will then execute. Once the preceptor’s recommendations are executed the note can be signed. Once the note is final signed the preceptor will need to cosign the note.
Fourth year medical students have the option of saving the note in the way that is done by third year students, or they can final sign. Every medical student note will need a co signature.
Resident notes must always be cosigned if a new diagnosis is added to a progress note, or if a procedure is performed. However, in practice, many physicians cosign all Resident notes regardless of content.
The trainee can forward the note to your message center inbox for signature when he or she signs or saves the note. Alternatively, you can find the note in the “documents” section of dynamic documentation or in the “documents” section of the PowerChart menu. Once you have selected the note you can modify to append your signature. If the note has not yet been saved you should not modify the trainee’s text; instead, you should ask the trainee to revise his or her comments based on your recommendations. This can be done through message center by sending the note back to the trainee, or through a personal communication.
When there is a question about coding or other medical records inquiry you will receive a message center request in your inbox. Please respond to this within 24 hours. The staff will directly convert your responses to their inquiry to a progress note in order to provide supporting documentation for their coding or other activity, so please use language that is appropriate for the medical record.
You will learn to use Dragon in the classroom training provided for physician documentation. In the classroom training session you will learn basic Dragon commands and other functionality at the same time that you are learning electronic documentation. In addition to the classroom session you can also receive one-on-one Dragon training that will help you to become proficient with the tool, and also will be an opportunity for you to customize the “quick commands” that will save time during documentation.
Beyond the initial Dragon training that takes approximately five minutes, it is important to correct any recognition mistakes by right-clicking on the mistake and correcting this from the menu. Over time, Dragon will become even more accurate if you follow these steps.
No, for now the “network version” that you use in the hospital for documentation is not available on your private computer that is remotely connected to ChristianaCare’s network system. This will likely change in the future.
If you would like to bring Dragon commands from your office system, during the classroom training ask the instructor to show you how to do this. Then, schedule a one-on-one session with a trainer so that your commands can be imported into ChristianaCare’s version of Dragon.
It’s best to schedule a one-on-one session with a trainer to gain experience in customizing autotext. In addition, a web-based video is available to help you do this [insert web link].
Yes, you can use quick orders at any time. If you do this you should be careful to ensure that the next time you create a note you delete it from your documentation. Every time you place an order (from quick orders or the orders tab) it will be pulled into a note created within 24 hours of the order. Any order you place will not be pulled into someone else’s note.
In the “consolidated diagnosis” menu item for the documentation workflow you have the opportunity to add diagnoses, designate them as “chronic” or “for this admission”. You also have the ability to sequence the diagnoses based on priority or other factors. Highlight the diagnosis number and a dropdown numeric list will display. You can pick #1, #2, etc. to associate with that specific diagnosis. This is an important step because the assessment and plan section of the progress note will be sequenced based on this list so that the most important diagnosis is at the top of the list.
Within the next few months you will be able to use the PowerChart tools for all your documentation. To support date/time/sign it was important to start with those document types that currently are on paper. It’s important that you remember not to use this tool for Admission H&P, Consultations, Operative Reports, or Discharge Summaries because these dictated and transcribed documents are tracked by HIMSS for timeliness and completeness
Wherever there is an available surface a computer has been added, to the point where many people think that too many computers are on the desktops. To facilitate the use of the vertically-oriented documentation tool, large monitors have been placed on the desktop in portrait orientation. While we recognize that this may cause communication and other issues, the vendor’s recommendation about large monitors oriented in this manner will enhance the documentation experience. We are working with the ergonomic team and others to ensure that these large monitors are ergonomically implemented. If there are too many PC’s, especially on the blackjack tables, we will remove one after go live.
Nurses should not be using the blackjack PC’s as every nurse has his or her own computer on wheels. Please ensure that everyone using a machine is doing clinical work; you should feel comfortable asking someone who is not using a machine, or not using it for clinical work to please step aside. Please call Dr. Terri Steinberg 302-593-4871 to report issues with access to computers on the units.
A document can be printed from the dynamic documentation window by clicking on the document to open it, then selecting the printer icon from the menu bar at the top of the document.
You can forward a note to another provider. You should open the note and click the portrait icon on the menu bar to select the name of the person to whom you would like to forward the document. They will then see that note in their message center.
The user interface for the new PowerChart documentation tool has been optimized so that documentation is a byproduct of clinical work. Consequently, new tools have been developed that are more streamlined than other tools in PowerChart. For example, “quick orders” and the “consolidated progress note” are easier to use in some circumstances than the problem list or orders module in PowerChart. It’s perfectly OK to use the tools that work best for your workflow.
Yes, in fact the best practice for quick text (.text) and Dragon commands is for groups of users to develop clinical content, and then to share these with everyone. This work is best done during training, especially during the optional one-on-one training sessions for which you can sign up.
Submit a request by clicking on the CPOE Order Set/ Dragon Request Form under Content and Links, found at http://inet/ExternalAffairs/cpoe.html
Enter the information in the required fields, including the type of request (Dragon-Change or Dragon-New). Provide the details of your requested Dragon command or template in the Issue/Comments field. Submit the form and you will receive a follow-up from a member of IT regarding your request.
You cannot save a quick order as a favorite but you can make favorites that can be used in quick orders. To make a favorite that can be used with quick orders you must order this in the “usual” way from the orders tab, and then right-click to save as a favorite. Once you have saved the favorite from the orders tab it will display within the quick orders favorites list.
For now, PowerChart is read-only on a smartphone or tablet device. If you would like to use this please send an email to Dr. Terri Steinberg at firstname.lastname@example.org. You are able to use PowerChart on a laptop through the Citrix client. Over the next year we will be rolling out the ability to create documents and enter orders with a smartphone. We will keep you posted about progress for this project.
PowerChart progress notes are unrelated to Centricity. The PowerChart discharge summary that is dictated and transcribed is now available in Centricity, as are the patient’s discharge instructions.
It’s true that DHIN will soon be a PowerChart menu item. When you select the DHIN item at the bottom of the list, if there are results in DHIN for the patient in PowerChart you will be presented with this information without needing to log into DHIN directly.
The functionality that allows a user to look for a specific result in PowerChart is called Chart Search. There is a menu item for chart search that will present a search field. Once you’ve entered a word into this field, “renal failure” for example, any document that contains this information, result or other chart component will be presented to you.
Yes, the discharge process needs some work, especially with respect to obtaining an accurate and complete home medication list at the time of admission. A consultant has been retained to review and optimize the discharge process.
The emergency department is now generating an electronic visit note. This will be in the PowerChart documents menu list for your review.
Yes, the Women’s area is now live with CPOE and both L&D and pediatrics will be live with electronic documentation at the same time as the rest of the house.
The NICU will remain on paper for orders and documentation for now.
The Surgicenters will remain on paper for orders and documentation for now.
No, transcribed documents including Admission H&P, Consults, operative reports, discharge summaries, and patient discharge instructions are sent to DHIN. Progress notes will not be sent to DHIN.
If the community physician has privileges at ChristianaCare, and network or PowerChart access, this will be a good way for the physician to follow his or her patient’s progress. If the physician is not on staff the progress notes cannot be reviewed.
A list of commands that can be used to pull information into the chart will be available to you as a job aid. This list is, typically, limited to common labs, Intake/Output, vital signs, ABG’s, etc. Additionally, you can specify additional items of interest to pull into the note through a process called “tagging”. Tagging is covered in training. How do I communicate information to another provider (inbox, sticky note, progress note)?
Yes, after you click “create note” you can revise the note to add or delete any information that is contained.
To tag information you can highlight a result, or text within a document or result, and right click that highlighted area. The option to “tag” this information will be available. When you click “create note” you will see this tagged information at the left side of the document in a separate pane. This tagged information can be dragged to any part of the note. If you don’t drag it into the document it will not become part of that note.
Within the progress note documentation workflow all documents that are useful in this workflow will pull into the document list. This includes nursing documentation, communication forms, Admission H&P, Consults, Operative Reports, etc. If review of another document type is needed you can click on the heading “documents” to navigate to the entire document list. When you’ve completed this review, you can use the back-arrow to return to the documentation workflow.
A final result has the status of “Auth (verified)”. A preliminary result status is “unauth”. “In lab” means that a specimen has been drawn but not yet run in the lab.
If you know the name of a specific provider to whom you would like to communicate a result, the message center/inbox is the best way to do this. If you don’t know the name of a specific provider, and want to communicate information to all providers, or to a specific physician group, you can generate a progress note that contains this information. You would not document any information in the workflow areas, but would immediately select “free text note” in which to enter your information. The note’s title would be “COMMUNICATION”. Needless to say, telephone communication remains a good channel for discussion.
The Dragon tool that you use in the office is slightly different from the version at ChristianaCare, but it’s similar enough that you probably don’t need much additional training. You should, however, come to class so that you learn how to document in PowerChart, and how to transfer your office commands to the ChristianaCare Dragon system.
A general video overview is available on the portal. This will provide a high level introduction to PowerChart electronic documentation.
The training schedule is available in the Education Center from the Physician Portal menu. In the Search field, type the course code mdpro14. Then click Go. If you experience an issue using the course code, try the keyword Progress. Find detailed instructions on the training registration process at cchsdotorg.staging.wpengine.com/powerchart2014. If you have questions about training, please call 302.327.3646 or email Betsy Vasquez at BVasquez@christianacare.org
During the go live you will see plenty of “green vest” support on the units. If someone is not readily available you can ask the unit clerk if a super user is available on the unit. If not, call the command center at 302-733-1576 (CHR) or 302-320-5210 (WLM).
At implementation, all rhythm strips or prints generated through hard-wired monitoring or telemetry will continue to be stored in the paper chart. However, we are working to migrate them to the electronic medical record in the near future.
EKGs are available electronically in the Tracemaster system. This system is available on the portal. To access this you will enter your same user ID and password that you use to log into the network.
For situations when the document must be immediately available for communication after a procedure or for some other event, a copy of the form should be placed in the STAT SCANNING bin at the nursing station. The unit clerks will send it to HIMS for scanning into PowerChart and an extra copy will be made to follow the patient and reside in the paper chart. This paper copy will be unnecessary once HIMS scans the document into PowerChart.
At implementation, the full eCare record will continue to be printed when a patient is transferred from an eCare ICU. We are actively working on a solution to incorporate this information into the patient’s electronic medical record in the near future.