documenting an operation note using the surgical op note ...€¦ · allow free-text typing of...

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Documenting an Operation Note

Using the Surgical Op Note (PowerNote) The Surgeon Op Note PowerNote is the document template to use to document Operation Notes. PowerNotes contain a range of features including:

▪ Ability to add Procedures and content from the Chart such as Orders

▪ Draw on and insert diagrams and pictures

▪ Customise Op Note Settings to save time

Table of Contents

Open a Surgical Op Note Page 2

Navigating the Surgical Op Note Page 3

Documenting in the Surgical Op Note Page 4

Adding the Procedure Performed Page 5

Streamlining your Search for Procedures Page 6

Editing how a Procedure is Displayed Page 7

Saving Favourite Procedures Page 8

Accessing your Saved Favourite Procedures Page 9

Adding Images within the Op Note Page 10

Placing Orders within the Op Note Page 11

Finalising the Op Note Page 12

Customising Op Note Settings

• Changing Font Size and Style

• Creating Pre-Completed Notes

• Creating Case Attendees with Macros

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Documenting an Operation Note Using the Surgical Op Note (PowerNote) V1 August 2018

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Open a Surgical Op Note

Open the patient’s chart/medical record and click on Documentation in the Patient Menu

NOTE: DO NOT click the Add button next to Documentation – this will not open the standard Progress Note templates.

In the Documentation screen click the drop-down arrow next to Add and select PowerNote

1. Open and use a Note by clicking on one of three tabs and double-clicking on aTemplate:

▪ Blank Surgical OP Note - Click the Catalog tab and click the Catalogdropdown menu and select Surgery

▪ Precompleted Tab

▪ Favourite Tab

The Surgical OP Note will open for editing.


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Navigating the Surgical Op Note

▪ On the left of screen is the Table of Contents

▪ On the right of screen is the Note Body

Table of Contents Note Body

The PowerNote will automatically include the surgical Case Number if you are in the correct inpatient encounter.

Mandatory fields show in the Table of Contents with a red Asterisk.

The Procedure Performed is the only Mandatory field in the Note.

Navigate via the Table of Contents by clicking the + next to each heading, then click on a subheading/section to jump to it in the Note Body.

Most of the sections in the Surgical OP Note allow free-text typing of information.


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Documenting in the Surgical Op Note

▪ Use the structure and document against a section by clicking on this symbol = = =

▪ For the Discharge Plan & Post-op Follow up, click on a frequently used Responseto select and include it in your final Note or add further instructions by clickingthe section ===

▪ Free-text parts of your note by clicking on a heading or section and clicking UseFree Text

Preview the finalised Note by clicking the very small Display Contributor View button on the right of screen directly above the Scrollbar.

Click it again to continue editing the Note.


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Adding the Procedure Performed

The Procedure Performed section is a Mandatory Field.

1. Click Add to Procedure History in the Note Body

2. Click Add

3. Add a procedure by typing in the Procedure within the search field andclicking the Binoculars to search for it.

Remember to add the procedure as a Favourite if you use it frequently, this saves time searching.


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Streamlining your Search for Procedures.

Modify the Procedure Search filters to get a more comprehensive Procedure search.

Change it to a Contains Search and click the ellipsis next to the Terminology Axis field and select Procedure.

You will only need to do this once on your personal login and it will default to these settings.

NOTE: If you cannot find the exact terminology for a Procedure, click on a Procedure that most closely matches it and click on View Synonym to see closely related procedures.


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Editing how a Procedure is Displayed

In the Add Procedure window you can add more details to a Procedure, or change how it displays in the Surgical Op Note and in other areas of ieMR.

1. Use the Comments field to add any details to a Procedure

2. Use the Display As field to have the Procedure display differently in thepatient’s chart from the SNOMED-CT nomenclature selected. Note theprocedure will still be coded as the procedure selected.

SNOMED CT nomenclature

3. Once any details have been edited click OK to add the Procedure or click OK& Add New if you need to add multiple procedures for the patient.

4. To include the Procedure in your Surgical Op Note select it from theProcedure History window and click Include – To add multiple Procedures tothe Note hold the Ctrl key to select each Procedure


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Saving Favourite Procedures

Save time typing and searching for commonly performed Procedures by using Favourite Procedures.

1. Type in the Procedure into the search field within a note

The Procedure Search window will open.

1. Single-click on the relevant Procedure and click Add to Favourites

2. Select or create and name a Favourites folder and click OK

3. Add more Favourite Procedures by typing in and searching for another procedurein the search bar of the Procedure Search window

If you are just saving Favourite Procedures click Cancel when finished so that you do not add these Procedures to the patient’s chart!


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Accessing your Favourite Procedures

1. Click on the Favourites folder at the bottom of the Add Procedure Window

2. Double-click on a Procedure to add it to the case

3. Add any additional details and click OK


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Adding Images within the Op Note

The Surgical Op Note PowerNote can have images added to it.

1. Click on the subheading/section you want to image to appear under

2. Click the Insert Image button in the Editing Toolbar at the top of the Note

The Drawing Box window will open.

3. Either free-draw into the box or follow below to use a pre-loaded image

4. Click the Open button

5. To preview the available images click the Change Your View button

6. Select an image and click Open

7. In the Drawing Box you can Trim and zoom-in on an image using the Editing

Toolbar

8. Draw on and edit the image as required then click OK – the image willappear against the section you selected


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Placing Orders within the Op Note

You can place Orders from the PowerNote

1. Click on either of these two sections to use this feature:

▪ Specimens Sent to Pathology? – Yes

▪ Post Operative Orders – Additional Orders

2. The Add Orders window will open

3. Click Add to place any new Orders if required

4. To include any Orders into the Note, multi-select any relevant Orders andclick Include Selected

The selected Orders will now be documented into the Note.


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Finalising the Surgical Op Note

1. Once the Op Note is completed click Sign/Submit

The PowerNote will now appear in all documentation areas of ieMR; Continuous Doc, Documentation and Clinical Notes View.

You can preview the finalised Note by clicking the very small Display Contributor View button on the right of screen directly above the Scrollbar.

Click it again to continue editing the Note.


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Customising PowerNote Settings

To save time documenting the Surgical Op Note PowerNote, you can create Pre- completed Notes as well as Favourite Procedures. Macros can also be created to save time entering in Case Attendees, and you can also change the Font Style and Size of the Note.

Changing Font Style and Size

You will only need to change the Font Style and Size once, this preference will save to your ieMR profile.

1. Open a new Surgical Op Note

2. Click on View in the PowerChart Menu at the top and select Customise

The Customise window will open.

3. Select the Font tab and edit the Font settings then click OK when finished

The following Font Styles and Size are recommended:

Style: Tahoma & Déjà vu Sans Mono. Size: 12


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Creating and Updating Pre-Completed Notes

Pre-completed Notes can be created to save time documenting an Op Note. These Pre-completed Notes can also be shared to other ieMR users in the same Hospital. You can edit and update Pre-completed Notes at any time.

NOTE: Images and coded Procedures, Problems and Orders cannot be saved into a Pre-completed Note.

1. Open and create a new Operation Note

2. Type up the Note in a format/template as desired

3. To save as a Pre-completed note click on Documentation in the PowerChartMenu and select Save as Precompleted Note

4. Title the Note and then click Save as New or Update Existing


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5. To use a Pre-completed Note when starting a new Op Note click on the Pre- completed Tab or if added to it the Favourites tab

Add a Pre-completed Note to the Favourites tab by selecting the Note in the Pre-completed tab and clicking Add to Favourites.

Updating Existing Pre-Completed Notes

1. Open the Pre-completed Note you want to update

2. Edit the note as desired then update the Note by clicking Documentation inthe PowerChart Menu and selecting Save as Precompleted Note

3. Click Update Existing


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Creating and Using Macros to Enter Case Attendees

Macros allow users to enter in saved phrases or sentences against sections in the PowerNote. This feature is useful for quickly entering in Case Attendees into the Op Note.

1. Open an Op Note and click on one of the Case Attendee roles – e.g.Surgeon(s)

2. Search for and select the desired person then click OK

3. When added you can right-click and Add Comment to add any additionalinformation against that Case Attendee

4. To save the person as a Macro right-click on them and select Save Macro As

5. Title the Macro as the name of the person then click Create New or Update

A blue M will display next to any section with Macros saved to it.


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Using Macros

To use a Macro to document against a section:

1. Click on the blue M and select the Person or Phrase you want to use

Macros can also be used to add commonly used sentences or phrases against any Section.


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