structured notes for care providers. describe the key features of a structured note. describe how to...

Structured Notesfor Care Providers

Describe the key features of a structured note.

Describe how to set default preferences. Identify which data will auto-populate

versus manual entry. Describe how to create an acronym

expansion. Identify how to assign for a co-signature.

Structured NotesObjective

Increased efficiency: Use of ‘copy forward’ like functionality Pulling data from other sources, e.g. VS, labs, meds,

health issues Drives compliance with key indicators – i.e.

device medical necessity Accessible anywhere by all providers Standardizes billing and compliance

language requirements

Advantages of Notesin QUEST

Physician: H&P Event Note Progress Note Procedure – Central Line Discharge Note Ambulatory Notes

Amb H&P Amb Well Child Amb End of Visit Amb Follow Up

Allied Health: Case Management Note Clinical Social Work Note ED Rapid Screening Exam Procedure – PICC Insertion Patient Profile Respiratory Care Note Spiritual Care Note Ambulatory Notes

Amb Intake Note Amb Triage Note

Examples ofStructured Notes

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Navigating Tools

Use the navigation button below or click a topic to proceed.

1. How to Enter a Note2. Creating a Preferred Documents List3. Basic Functionality4. How to Manage/Modify5. Pulling Data Into the Note6. Modifying Template7. “My Default” Exam8. Acronym Expansion9. Use of Health Issues within the Note10. Adding a Co-Signer11. Changing a Co-Signer12. Attending Attestation13. Unfinalizing a Note14. Conclusion

Table of Contents

To access a structured note, first select a patient and then click Enter Document icon.

Structured Notes:

How to Enter a Note

Type the first few letters of the document name to begin the search (no need to hit <Enter>).

Structured Notes:

How to Enter a Note

Once found, highlight the note and click .

Structured Notes:

How to Enter a Note

Notes frequently used can be saved as a list of “personal documents.”

Structured Notes:Creating a Preferred Documents List

To create your list of Personal Documents: Select a patient. Select the Preferences Menu. Select Document Entry…


To create your list of Personal Documents: (cont.) Click the to open each section Highlight your note and click


To create your list of Personal Documents: (cont.) Now, go to the Browse Start Point tab Select Personal Documents Click Set As Default


By setting Personal Documents as your default, Enter Document icon will always launch to your default view.


All structured notes have the same basic functionality: BLUE exclamation points ( ! ) are required

fields to “complete” a note.

RED asterisks (*) are mandatory fields to “save”

a note. Multiple check boxes ( ) can be selected, but

only one radio button ( ) can be selected per section.

Structured Notes:

Basic Functionality

To remove a selected radio button ( ), right-click and select Delete Data.

If an option with an ellipse (…) is selected, additional data fields will appear.

Structured Notes:

Basic Functionality

Use the navigation buttons to move between document sections, when available.• or navigates to the next or previous section.• or navigates to the first or last section of the

structured note.

Structured Notes:

Basic Functionality

Another way of navigating within the note is to hover the mouse over the Sections tab, located at the top-left corner.

Click the and select the specific section you would like to view.

Structured Notes:

Basic Functionality

Most structured notes have the current Date and Time auto populate upon opening.

Make sure your name appears in the Accessing Provider field.

Structured Notes:

Basic Functionality

Structured notes have a 20 minute lock-out feature to prevent concurrent charting.

There is a potential to lose unsaved data beyond this time.

When all “required” and “mandatory” fields are filled, the note can be saved as complete or final.

Notes that require a co-signature can only be saved as incomplete. Once the note is co-signed, it can be saved as final.

Structured Notes:

How to Manage / Modify

Whenever given the option, Submit as Final is the preferred method of saving.

Final Documents cannot be modified. Free Text notations may be added using the “Append” function.

Structured Notes:


Edit saved notes within the Documents tab First, highlight the note. Then right-click.

Modify Document – to edit a complete or incomplete note. Cancel Document – to delete a note entered in error. This will

display as a lined out item and cannot be reinstated. Append Document – to add documentation to a finalized note.

Structured Notes:


The Preview tab is to view the note in its entirety. The Preview option displays in real time, which can be

used to review the note during documentation and prior to saving.

Structured Notes:

Pulling Data Into the Note

Notes may contain “pull sets” that retrieve data from other applications. Only selected checkboxes of a “pull set” will populate the note. Below is an example of a “pull set.”

Structured Notes:


If pull set data need to be changed, use the application icons (examples below) to update the patient information while in the note.

Otherwise, erroneous data will always exist.

Structured Notes:


If needed, click the Refresh icon to populate the pull set with the updated information.

Structured Notes:


Notes may also have medical logic modules (MLMs) that allow data to populate your note. An example is lab results.

Some MLM text fields will allow for information to be added or deleted.

Structured Notes:


Some MLMs are on-demand options.1. Select the radio button2. Check mark the info to populate the note3. Click OK

Structured Notes:


Notes may provide options for documentation preference. An example is shown below:

Physical exam (free text) Physical exam by individualized systems (default)

Structured Notes:

Modifying Template

Before documenting on the note, select Modify Template.

The template can only be modified when data do not exist in the section that will be modified.

Structured Notes:

Modifying Template

Choose your documentation preference and deselect the other:

Physical exam by individualized systems (available as default)

Physical exam by all systems (free text)

Structured Notes:

Modifying Template

After making your choice, check mark Save template for me and then click OK.

This recalls your setting every time you open the note, regardless of the selected patient.

Structured Notes:

Modifying Template

When the option Save as Default is available, create your default information first. Fill out each text field for that section. Then save it as your default.


Physical exam by individualized systems

Structured Notes:

“My Default” Exam

SUGGESTION: Retrieve your “default exam” or “my last exam for patient” before entering any free text. Otherwise, the free text will be overwritten.


Physical exam by individualized systems

Structured Notes:

“My Default” Exam

Because structured notes have text fields, using Acronym Expansion can be helpful.

To setup your acronyms, select Preferences > Acronym Expansion.

Structured Notes:

Acronym Expansion

Click Add to create your own acronym or click Import From Other User.

Structured Notes:

Acronym Expansion

In the Acronym field, type an acronym. It is suggested to begin some acronyms with a

period (.) to prevent unintentional acronym expansion.

In the Expanded Text field, type the full text of the acronym.

Click Apply to create more acronyms.

Structured Notes:

Acronym Expansion

When importing from another user, use the dropdown list or type a person’s last name.

Structured Notes:

Acronym Expansion

Place a checkmark next to the acronyms you would like to import and then click OK.

Structured Notes:

Acronym Expansion

REMINDER: Acronym expansion is case sensitive. For example, “bid” will not expand to “twice a day” because the acronym is in caps.

Structured Notes:

Acronym Expansion

Health Issues management can be done from within a note by clicking the Health Issues icon.

Structured Notes:Use of Health Issues within the Note

Drag and drop the order/medication on top of a health issue in the Problem List.


The order/medication will not associate if dropped in a blank area.

Blank Area


Check mark Include Linked in order to associate an order/medication to multiple health issues.


Single click in the text box to document your Assessment and Plan for each Health Issue.


To take out data entered in error, remove the check mark.


To assign a note for co-signature:

Select the Document Info tab

Then check mark the Co-Signer checkbox

Structured Notes:

Adding a Co-Signer

Select the co-signer’s name from the list of available current providers.

Structured Notes:

Adding a Co-Signer

If the co-signer’s name is not listed:

Delete the name in the Care Provider field.

Type the co-signer’s name.

Click Search. If multiple names appear,

select the correct name.

TYPE NAME HERE

Structured Notes:

Adding a Co-Signer

If the designated co-signer needs to be corrected, it can be changed using Signature Manager.

If the icon is not readily available, you can use the menu option Go To > Enter/View > Signature Manager.

Structured Notes:

Changing a Co-Signer

To change the co-signer through Signature Manager:1. Change Provider Selection to

Selected Providers.

2. Click the ellipsis (…) to search for the co-signer’s name who was identified in error.

3. Narrow the Item Type Filter to “documents” only.

4. Select Reassign.

5. Click Get List.

Structured Notes:


To change the co-signer through Signature Manager (cont.):6. Check mark the note that needs to

be re-assigned.

7. Click Reassign.

Structured Notes:


To change the co-signer through Signature Manager (cont.):8. Click the ellipsis to search for the correct co-signer.

9. Enter the reason for re-assigning to a new co-signer.

10. Click OK.

Structured Notes:


Billing Service Level and Attending Attestation sections of a note are for Attending use only.

Structured Notes:

Attending Attestation

The Attending Evaluation Date/Time is a manual entry for when the Attending does the attestation.

Structured Notes:


Attending Attestation: Provide Attending attestation statements for different scenarios; additional comments as appropriate.

Structured Notes:


When the Attending is ready to finalize the note, select Note Finalization.

Once finalized, the note cannot be modified.

Structured Notes:


In the event a note was finalized in error, only the Attending can unfinalize that note.

Notes can be unfinalized on “active” visit accounts only.

Visit accounts are no longer active after 14 days post discharge.

Structured Notes:

Unfinalizing a Note

To “unfinalize” a note:1. Highlight/Select the note

2. Right-click

3. Select Unfinalize Document

Structured Notes:

Unfinalizing a Note

To “unfinalize” a note (cont.):

4. Answer the prompt.

5. Then right-click again on the note to modify.

Structured Notes:

Unfinalizing a Note

When re-finalizing the note, notice that Note Finalization is already marked.

You must uncheck Incomplete in order to save and finalize.

Structured Notes:

Unfinalizing a Note

For issues with a structured note, contact the Help Desk at (714) 456-3333.

Structured Notes:

Conclusion

You have reviewed: The functionality of a Structured Note. How to create acronym expansions. How to designate a co-signer. How to modify your template. How to set your default preferences. How to re-assign to the correct co-signer.

Structured Notes:

Conclusion

You have completed the course.

DISCOVER ● TEACH ● HEAL

Structured Notes:

Conclusion

structured notes for care providers. describe the key features of a structured note. describe how to...

Documents

default structured notes

examples of structured

note unfinalizing

saved notes

preferred documents

basic functionality

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