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Overview of Doctor View and Documenting Admission Note

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Overview of Doctor View and Documenting Admission Note Quick Reference Guide (QRG) Overview of Doctor View and Documenting Admission Note The Doctor View is the default screen when opening a patient chart. It houses the most commonly accessed details and functions required for patient care. The admission note is expected to be generated using the Inpatient Workflow mPage found in the Doctor View Doctor View Customising the Inpatient Workflow Open the patient’s chart. The flow of documents in the menu This will open the Doctor View and the main can be customised by clicking on a tabs. menu option and dragging and dropping to the preferred location • To add or remove headings from the menu list, click the list icon (top right of Inpatient Workflow doctor view) and Components, tick/untick options to show/hide menu options. • Used to generate admission/ward round notes • Contains commonly accessed patient details as well as free text fields to complete which populate the note Quick Orders • Surrogate view of the Orders tab in the table of contents The customised view is saved. • Users can quickly add commonly selected pathology, radiology and medications Click Clear Preferences to reset to default orders Patient Timeline Using Doctor View • Surrogate of the Observation Chart tab in • To review the Inpatient Workflow mPage the table of contents you can press Tab on the keyboard or • Shows a diagrammatic view of patient’s click the section headings to move observations and medication chart between the relevant sections. • There are five free text fields for doctors to Discharge enter information about the current status of the patient. • Used to generate the discharge summary I.D. 205 V2.0 18/06/2019 2 1. Chief Complaint (the overarching one sentence summary of the patient) 2. History of Presenting Complaint Documentation: Create a Note 3. Physical Examination Create a note via the Inpatient Workflow mPage 4. Impression • Select a note type from the bottom of the 5. Plan Inpatient Workflow menu. If none of the note types displayed are appropriate, • 4 of these free text areas may be ‘pushed select ‘Select Other Note’ out’ to remain static on the screen. Click onto the small arrow which will push out the selected section. • These 4 fields are refreshed once a note has been generated and are blank to be ready for the next note to be written. • A new document will be created, of the selected note type. Your input will be automatically drawn into the new document, provided it has headings for that component o e.g. Admission Note contains all headings • Click Save or Sign in every section o Medical Ward Round Note does not separately after you enter information. contain past history (problems designated as ‘chronic’) • The remaining sections in Inpatient Or Workflow are not free text fields. They allow for various actions, such reviewing vital signs and ordering medications. Clicking on their titles will link to other Create a note via the ‘Documentation’ menu options from PowerChart, for tab example Problems List takes you to Diagnosis, Alerts and Problems. • Select Documentation from the Main menu and click + Add. • You may also ‘Tag’ specific results such that they appear in the note generated • Select a note ‘Type’ • After the 5 free text fields have been completed, a documentation note needs o For example, ‘Medical Admission Note’. This alerts the EMR to the type to be created. of note you are creating. This allows Quick Reference Guide | Overview of Doctor View and Documenting Admission Note I.D. 205 V2.0 18/06/2019 3 the note to be filed in the appropriate type], General Medicine Registrar Admission folder in Form Browser or Notes tab. Note) • Select a ‘Note Template’ Any additional information after this time will o For example, ‘Admission Note’. This be saved as an addendum. determines what layout you will be given when you create your note. • To add an addendum, select the document as it appears in the Tip: If you select ‘Medical Admission Note’ documentation list. type, and ‘Free Text Note’ template, you will create a blank note that the EMR will classify Click the button. The document as an admission note. will open, and an addendum may be added at the bottom of the note. • Click on the star icon beside the note template to add to Favourites. • Click ‘OK’. If you have selected an appropriate template, the information entered in the free text boxes in the Doctor View will automatically populate the appropriate sections. • Review the note in the documentation template. Information can still be added or edited here. • Unused headings can be deleted by hovering over the headings to make a cross appear. Remove section from the note. Refresh section to pull information from Doctor view. Insert free text entry. • To save a note (with the ability to edit further) click Save. • Update the Title with the ‘Team, Role, Reason’ format – for example ‘Respiratory, Registrar, Admission’ • To finalise the note, click Sign/Submit. Tip: Ensure correct document naming conventions (i.e. [Specialty] [Position] [Note Quick Reference Guide | Overview of Doctor View and Documenting Admission Note I.D. 205 V2.0 18/06/2019 .
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