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.
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.
Sticky notes in the chart will be replaced by a number of different tools:
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.
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:
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.
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.
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.
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.
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 email@example.com. 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.
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.
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)?
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.
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
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.