Understanding Note Types, Templates, and Workflow in Clinical Documentation, Study notes of Radiology

Download Understanding Note Types, Templates, and Workflow in Clinical Documentation and more Study notes Radiology in PDF only on Docsity!

DYNAMIC DOCUMENTATION

DYN DOC BASIC ANATOMY REVIEW

• Dynamic Documentation
• Note Type vs Note Template
• Workflow mPages
• EMR Content
• Autotext and Smart Templates

TERMINOLOGY: NOTE TYPE VS NOTE TEMPLATE

• Note Type =
  • Used with both PowerNotes and Dynamic Documentation
  • Selected by the provider to identify the type of information contained within his/her note
  • Used to organize and filter notes both in the back end and by the end user
  • Ex: OP Primary Care Sick Visit Note, NW Admission H&P, LTC Progress Note, ED Procedure Notes, etc - Note Template = - New with Dynamic Documentation - The blueprint of the note - Constructed in the background - Composed of sections and subsections - Dictates which EMR Content or Smart Templates are pulled into the note and where they go - Each Note Type is mapped to a Note Template - Ex: Office Note, Admission H&P, Progress Note, Procedure Note, etc

TERMINOLOGY: WORKFLOW MPAGES

• MPages provide a single consolidated view of information that is contained throughout the medical record
• MPages have existed at YKHC since Cerner was originally launched
• Types of MPages –
  • Summary MPages
  • Workflow Mpages
• Mpages are made up of Components, such as Allergies, MultiMedia Manager, Patient Education, etc
• While the use of Workflow Mpages is new with Dynamic Documentation, Workflow Mpages and Dyn Doc are distinct

TERMINOLOGY: AUTOTEXT

• Autotext
  • Personal or global phrases, which can be stored and reused by typing in an abbreviation.
  • All YKHC global abbreviations begin with .. (two periods) such as ‘..rosbasic’ (Basic Review of Systems), but your personal autotext may begin with any combination of letters that you would not accidentally type on a normal basis
  • These are case sensitive, and 99.9% of global autotext are currently all lowercase
  • Autotext is not new with Dyn Doc, but increased use of autotexts is recommended due to the loss of PowerNote’s Macros
  • Features of Autotext:
    • Insertion of _ (underscore) to tab quickly from one place in a text to another using the F3 key
    • Dropdown fields can now be built into autotexts when a choosing from a list of items would be convenient

TERMINOLOGY: SMART TEMPLATES

• Smart Templates
  • They are build with very specific parameters
    • Specific types of clinical information (Allergies, Problems, Labs, Vitals, etc)
    • Specific time frame and/or number of occurrences
    • Variety of formats (Tables, Lists, etc)
  • Can be added to Autotext or embedded directly into the note template
  • YK Smart Phrases (..YK) that you are familiar with using are still available for use

Using the Workflow:

• Accessed through Viewpoints
  • PowerChart: Ambulatory View & Inpatient View
  • FirstNet: ED View
• User designed workflow
  • Begin creating the note while interacting with elements of the chart review
  • Order the flow of the chart review and note creation in a manner that is intuitive for the individual user

CREATING A DYN DOC NOTE:

DOCUMENTATION TAB VS. WORKFLOW

MPAGES AND PROMOTING INTEROPERABILITY

While the creation of the clinical note may be more direct, the use of the workflow mPage ensures that the provider is documenting elements of patient care required for reimbursement in a way that is reportable…

• Completion of specific components: Patient Education
• New components created for Promoting Interoperability : Health Concerns; Goals and Interventions
• Actions required within existing components : Reconciliation of Allergies and Medications
• Reconciliation now required for Unverified Data from Outside Sources: Problems, Allergies, Medications, Immunizations (Look for the purple diamonds) - Commonwell - Clipboard - FHIR API

CLIPBOARD AND FHIR/API UPDATE

• Patient Provided Information
• Promoting Interoperability requirements are fulfilled as part of the registration

process – Access Offered (Go-Live for Registration changes is scheduled for 4/15)

• Clipboard: Data collected from the patient related to Problems, Allergies,

Medications and Immunizations, Custom Forms

• FHIR/API: Data collected by the patient using apps such as fitness trackers and

dietary trackers

• Not yet live – will initially go live with a patient subset (Women’s Health)

MOVING FORWARD: DYN DOC WORKGROUPS

• We have created small focus groups that can represent each department and

their needs.

• Within the workgroups we are reviewing the items within the workflows and

note templates that can be altered to create a better charting experience.

Note Templates:

• Refine the Demographics section by removing the often inaccurate PCP field
• Reorganizing template layout – move Labs and Radiology to the top of the

right column

• Changing filters for Vitals and Labs to improve the quality of information

pulling into the note

• Creation of smart templates to easily pull additional information

DYN DOC WORKGROUP RECOMMENDATIONS

While we are currently making a first pass at improving the workflows and note

templates before the change freeze, we would like to retain provider

workgroups so that we can relay information and gather feedback that is

department specific