Connect Care Tips: Documentation

Showing posts with label Documentation. Show all posts

Tippy - Updating Primary Care Provider Associations

Tippies can be quickly adopted with immediate workflow benefits...

Updating a Patient's Primary Care Provider

Connect Care uses information about a patient's primary care provider (PCP) to facilitate a number of automated communications. These can include:

admission, discharge and death notifications
consultation and referral tracking
alerts to key test results, and
sending copies of summative documents (e.g., operative reports, discharge summaries)

Although patients are asked to confirm their primary care provider at every Connect Care registration, changes can occur between the start and end of an encounter. It is important for providers to know how to change the primary care provider name (or clinic) associated with a patient chart.

Editing PCP information is easy. Either select (click on) the Storyboard (leftmost column of any open chart) row where provider names appear, or use chart search to jump to the "Care Team" chart activity. A "Patient Care Team" section has a tool for adding a PCP.

This is used to identify a PCP when none was previously specified. The same tool is used to enter a new PCP name to replace a previous outdated PCP association.

The current PCP attachment is highlighted in "Transition Planning" reports that appear in the sidebar of inpatient, emergency and outpatient charts, as well as admission and discharge navigators. Selecting the PCP link will open an advanced PCP attachment editor that supports attachment management. Communications can be generated to confirm attachments or request new attachments.

For more information:

Tippy - Fast Prescriber and Team Updates from Patient Lists

Tippies can be quickly adopted with immediate workflow benefits...

Quick Changes to Prescriber and Team Attachments within Patient Lists

Clinicians caring for panels of inpatients often depend upon timely information about which patients are attached to inpatient teams. Many Connect Care system behaviours depend upon correct patient-attending attachments.

The default workflow is to open a patient chart, go to the "Care Teams" activity, then update information about attending, referring, primary care, consulting or teams of prescribers associated with the patient.

A faster workflow is to edit patient attachments right within patient lists, avoiding having to open each chart. This is supported when AHS-recommended list templates and columns are used (see Manual link below).

To change an attending, referring or primary care provider, just double-click on the current (or blank) name. A focused pop-up editor will allow correction of that detail.

To change prescriber-patient attachments for many patients at once, select all (CTRL-A) or multiple (CNTRL plus click on the desired multiple rows) patients, then right click, and select.

Tippy - Pend, Share or Sign a Note?

Tippies can be quickly adopted with immediate workflow benefits...

Pend, Share or Sign a Note?

Automated actions can be triggered by the signing of a note. For example, signed summative documents (e.g., discharge summaries) are automatically shared with Netcare and primary care providers when signed. After a document is copied to external systems, additional work is required if the same document needs to be re-shared. It is especially disruptive for community practices to sort through multiple copies of shared documents.

Best practice makes use of two alternatives to signing:

"Pending” a note saves its current state as a draft but does not trigger any automated distributions. The author can return at any time to complete the note. Other authorized prescribers (e.g., attending physician) can take over a pended note by opening it for “Edit”. Pended notes appear within the “Incomplete” tab of the Notes activity within an opened chart.
"Sharing” a note saves the current state as a draft and does not trigger any automated distributions. The author, and other members of the clinical team (e.g., other trainees), can continue to work on the summative report. Authorized prescribers (e.g., attendings) can also take over a shared note by opening it for “Edit”. This workflow allows teams to collaborate in the preparation of summative documents, like discharge summaries.

Pended and shared notes are not available for viewing outside Connect Care, or the current Connect Care patient encounter. Once an authorized prescriber signs a pended or shared note, it becomes finalized, is visible on the appropriate Notes activity tab, and automated distribution actions (e.g., primary care provider copy, Netcare copy) are triggered. Any manual routing should be saved until after the note is signed.

For more information:

Manual: Shared Documents

Tippy - F3 to Expand

Tippies can be quickly adopted with immediate workflow benefits...

F3 to Expand Edit Area

There are many Connect Care activities where text can be entered and edited. Examples include notes, In Basket communications, problem overviews and handoff reports.

Sometimes editing is easier if the edit area is bigger. That's what F3 does. Press the F3 (function) key from within any text editing tool, and the edit space will expand to a near full-screen size.

An F3-enabled edit area is recognized by its tools button bar. Comment boxes, for example, do not have these buttons and do not respond to F3.

When dictating (Dragon Medical One), if this F3 functionality is important, create a custom command with a single step as illustrated:

Tippy - Fast Notes

Tippies can be quickly adopted with immediate workflow benefits...

F2, Spacebar, Enter = Fast SmartText

SmartPhrases and SmartText can make documentation a breeze. Indeed, it is possible to complete a complex note without taking fingers off the keyboard.

Commonly used within notes and communications, SmartPhrases and SmartText help set the form and flow of a note, using active placeholders (e.g., SmartLinks, SmartLists) to pull in patient-specific details from elsewhere in the chart. When working with a text automation:

The F2 key jumps from one placeholder (***) to the next.
When in a SmartList, use the spacebar to select a list item(s) and use the Enter key to move to the next smart item.
Yellow lists allow only one selection, whereas blue lists allow multiple selections.

If using a pointing device within lists, left-click (=spacebar) to select and right-click (=enter) to proceed.

If dictating (Dragon Medical One), say "next wildcard" to move from item to item, then left-click to select and right-click to proceed.

Tippy - Undo

Tippies can be quickly adopted with immediate workflow benefits...

Ctrl + Z = Undo

Regret is common when getting to know Connect Care text automation tools. It is easy to pick the wrong SmartPhrase, for example, and then want to pick something different. Undo is available from the editing menu just above the note or letter content being edited (just like a word processor).

It can be faster to press the control key and the letter "z" at the same time (if using a Mac, make sure that you have the right key-mapping enabled). This Ctrl+Z convention is widely followed in computer software.

If dictating (Dragon Medical One), pause and say "undo that" or "undo last action".

Tippy - Time-Mark for Notes

Tippies can be quickly adopted with immediate workflow benefits...

Time-Mark in Notes Review

A prior Tippy highlighted the value of "Time-Mark" in results review. It is possible to mark all viewed lab results as viewed, so the next time one opens the chart all the new results not previously seen are highlighted (bold font).

A parallel convenience is available when reviewing documentation notes:

Clicking on the "Mark All as Not New" command will cause all notes to be marked as already viewed. The next time one opens the chart and there is new documentation content, the unseen notes are highlighted with bold titles.

Tippy - Tag Notes for Easy Retrieval Later

Tippies can be quickly adopted with immediate workflow benefits...

Tag Important Notes for Ease of Retrieval

The Notes activity within inpatient charts supports "tagging", as does the Notes tab within the Chart Review activity of all charts. Any progress note, summative note or other displayable documentation can be marked with a "tag". A Tag icon appears in the tool bar of these activities (easily recognizable). When selected, a pop-up allows quick application of one or more tags to the current note. Options include tags like "Summary".

The Filter and Sort tools within notes displays can be set to limit displayed notes to those with tags attached.

In this way, clinicians can highlight key notes from among the many that may be found in a patient's chart. Milestone documentation, for example, can be filtered for quick review.

Tags are shared. Accordingly, any care team member can use the same filter to focus on tagged notes.

Give tagging a try!

Tippy - Documenting with Images

Tippies can be quickly adopted with immediate workflow benefits...

Embedding and Linking Images in Documents

Images, diagrammatic or photographic, offer a great way to record important clinical observations. A picture of a pressure ulcer, for example, best communicates about the evolution of a wound and its response to treatment.

There are different ways of working with images in clinical documentation, and the method chosen has implications for note readability and for compatibility with external systems that Connect Care may share with.

Progress Documentation
(e.g., progress notes) should use image links unless the reader would benefit from comparing a few fully embedded images. Progress documentation remains within Connect Care, embedded links are easy to use, and the resulting notes are easier to read.
Summative Documentation
(e.g., History & Physical, Discharge Summary, Procedure Note, Consult) should not use image links because these documents are shared with external systems that may not be able to view the links. If it is clinically important to include high-value images, then embed no more than 2 and size each to the smallest dimensions adequate to the documentation need.

Embedding or linking images within documentation is easy, as illustrated in tip sheets:

Problem Oriented Charting - Generating Summative Documentation

While problem oriented charting (POC) assessment and plan (A&P) notes typically appear within POC progress notes, A&P notes are also incorporated into POC summative documentation (e.g., admitting history, consult and discharge summary notes). This happens automatically when "Advanced" templates are selected from the sidebar notes index, or when "Advanced" speed buttons are selected from the documentation sections of admission, transfer and discharge navigators.

As with progress notes, only newly (since the last POC note signing) entered or edited A&P text blocks are pulled into new summative notes.

Provincial standardized templates can be inserted into any note editor by searching for SmartText with "POC Advanced" as a keyword.

For clinicians working with their own SmartPhrase personalizations of provincial summative templates, the ".HPROBPOCLASTAPOVP" SmartLink can be used to pull a prose-friendly list of new/edited A&P text blocks into documentation.

Problem Oriented Charting - Generating a POC Progress Note

Once a Subjective & Objective (S&O) text block and one or more problem-specific Assessment & Plan (A&P) text blocks are ready, a problem oriented charting (POC) progress note can be generated. This is done with the "Generate Note" button at the bottom of the Problem List section of the POC navigator.

A Progress Note will be generated and set up in the chart sidebar for editing. This will pull in the latest S&O text block as well as any newly created or edited A&P text blocks, while also adhering to the AHS standard "APSO" format for progress notes. Any text in dark blue font can be selected for "interactive charting" access to relevant additional information or editing tools.

There are two "Optional" SmartLists, activated with the F2 key. If left untouched, the lists are automatically deleted on note signing.

The first F2 SmartList supports the addition of one or more additional POC text blocks to be added at the top of the progress note. If the note is to serve as a weekly attending handover summary, for example, including the "patient presentation", "active problem list" and "hospital course" could be helpful.

The second F2 SmartList supports optional addition of discharge planning (from the Connect Care transition planning tools) or patient/family communication comments.

POC progress notes are best "shared", rather than pended or signed, so that other team members can view and contribute until the day's documentation is complete and the note is signed. Signing the POC progress note will lock-in the S&O and A&P components, allowing for new S&O and A&P text blocks to be generated for the next POC progress note.

Problem Oriented Charting - Assessment/Plan Documentation

Problem assessment and plan (A&P) text blocks are time-specific records of the latest status and management of health problem(s) appearing in a patient's list of hospital problems. Each problem has its own A&P block.

A&P blocks are combined with subjective & objective blocks to create a POC progress note. They are also pulled in to any of the "advanced" summative documentation templates (e.g., admitting history, discharge summary, consult). Only those A&P blocks that were changed since the last note are pulled into the next note, and any prior A&P note is always copied forward to a new A&P note. In this way, clinicians can keep documentation focused on new or updated A&Ps, while saving time by having any prior planning text available to edit.

Typically, A&P blocks are created or revised after creation of a Subjective & Objective note. New or revised A&P blocks remain in "current" status, available for editing by any member of the clinical team (for the specialty selected in the POC navigator), until a new progress or summative note is created.

When no current A&P block exists for a problem, the POC problem list indicates that an A&P block can be started.
When an A&P block has been started but not yet locked into a progress note, then the problem A&P area indicates that a block exists and can be edited.
As soon as a POC progress note or summative note is signed, it "locks in" the last A&P note. The problem A&P area changes to indicate that a new note can be created. The last signed note is available for quick review. It is also possible to review all past A&P notes about the same problem.

All A&P text block editors support dictation and SmartStuff so that SmartPhrases and SmartText, for example, can be used to speed text generation. The content of the last problem and specialty-specific A&P text block is automatically copied forward.

A&P Format and Style Recommendations

The best A&P notes are unique (do not replicate information elsewhere in the chart or destination note), succinct (keep to a single paragraph) and adhere to a consistent style that is easy to read. We recommend that the assessment be entered as plain text and the plan as bulleted points (see image above). The bullet-list toolbar item can be added (if not already present) by using the "Modify Toolbar" menu item in the A&P text editor.

Problem Oriented Charting - Subjective/Objective Documentation

The problem oriented charting (POC) "subjective & objective" (S&O) text block is combined with problem-anchored "assessment and plan" (A&P) block(s) to generate a POC inpatient progress note. S&O notes are not part of outpatient POC workflows.

The S&O text block might be started while rounding. It remains available as a "current" note for editing by any member of the clinical team (for the specialty selected in the POC navigator).

When no current S&O block exists (either there has never been an S&O during the current encounter for the specified specialty service or the last S&O block has been locked into a progress note), the S&O navigator section indicates that an S&O block needs to be started.
When a S&O block has been started but not yet locked into a progress note, then the S&O navigator section indicates that a block exists and can be edited.
The most recent S&O already locked into a progress note is shown for reference in the navigator section.

When a S&O block is first created, a SmartList presents (use F2 to activate) 4 options for setting up the new block:

Blank - Clears the block so that no templated material remains and the user can proceed with a personal SmartPhrase or simple typed or dictated text.
Headings - Sets up the block with standard settings but no other content.
Basic - Sets up the block with additional SmartLists (F2 to cycle through) that facilitate pulling chart information (e.g., vitals) into the block.
Advanced - Sets up the block with all of the Basic features, plus SmartBlocks for rapid entry of pertinent symptoms and signs.

All S&O templates allow further addition of SmartStuff and all support copy-forward of prior block content. The Basic and Advanced templates remind users that POC charting is all about brevity, recording only what is new and important since the last progress documentation.

Problem Oriented Charting - Specialty Service

Problem Oriented Charting (POC) tools are configured so that each hospital service (e.g., General Internal Medicine, General Surgery) works with its own subjective-objective note and its own problem-specific assessments and plans. Other text blocks, such as the patient presentation and hospital course, are shared by all specialties.

A "Select Hospital Service" section appears at the top of the POC navigator. POC users should select an appropriate specialty. This "notes" specialty is the same one selected when any new documentation (progress note, consult, etc.) is created. If a specialty is selected, then a POC task is completed (e.g., generating a POC progress note), the specialty will not need to be re-selected the next time the same chart is opened by the same provider.

POC continuity across Service Transfers

The POC work of one specialty can be viewed by another specialty. The notes service is a separate data element from the hospital specialty service that a patient is admitted or transferred to. Accordingly, a patient can be transferred from, for example, the "Hospital Medicine" service to the "General Surgery" Service but both services can still view the POC work of the other service simply by changing the service selected in the POC navigator.

In the case of a transfer, the receiving service may want to pick up the Assessment and Plan (A&P) POC notes from the sending service. One option is to "copy forward" a prior A&P note, using the icon provided for this in the text edit toolbar. A pop-up window will list all A&P notes, where the desired source will need to be identified (click to preview) then inserted.

We recommend using the "Select Hospital Service" section of the POC navigator to temporarily change to the sending service, then copy any A&P notes of interest to the "Pasteboard", then switch the service back to the receiving specialty and use the pasteboard to bring across the work of the sending specialty (see demo).

Problem Oriented Charting - Hospital Course

The "Hospital Course" is a problem oriented charting (POC) building block available to inpatient encounters. It allows clinical teams to collaboratively update a running summary of the patient's hospital experience. The text block can then be pulled into progress notes (e.g., weekly handover notes), transfer notes and discharge summaries. There is but one note per inpatient encounter, and all clinicians can share in its Wiki-like maintenance.

Hospital Course editing can be accessed by:

Using the hospital course section in problem list and POC navigators.
Selecting the "hospital course" title from the POC sidebar (opens pop-up editor)
Selecting any related document section title (e.g., "Inpatient Course" in discharge summaries; opens pop-up editor).
Selecting the right-pointing arrow in the inpatient sidebar index next the "Problem Charting" item (opens editor in sidebar).

A standardized Hospital Course format and style can maximize impact:

Brevity - Intended as a high-level overview of what happened during an encounter, keep to a maximum of a paragraph or two. This is not a detailed diary, but rather a tally of key milestones. For example, rather than listing all antibiotic agent details, indicate things like when step-down from parenteral to oral antibiotics occurred. Do not repeat information that will appear elsewhere in final documentation (e.g., discharge summary).
Format - A succinct prose comment on the overall hospital experience, followed by a bulleted list of key milestones, is preferred by the intended audience (e.g., community providers post-discharge).
Time indicator - It is better to indicate time intervals by the hospital day rather than by actual dates (which force the reader to calculate the relative timing of events).

Problem Oriented Charting - Patient Presentation

The "Presentation" text block is used in problem oriented charting (POC) outputs. It appears at the top of the POC sidebar, giving a quick sense of how the patient presented and why.

The presentation block can be inserted at the top of progress notes (e.g., when those serve as a weekly summary) and it is incorporated into all "advanced" summative documentation (admission history, discharge summary, consult, etc.).

Like other POC building blocks, the patient presentation is interactive. Click on any dark blue text to activate a pop-up "SmartForm" for editing the underlying structured data:

Help - Embedded help links are signified with the "?" character, which can be selected to access more information about the intent and use of patient presentation data.
Buttons - Facilitate rapid entry of commonly used options for a particular data element. These can be ignored and free text entered in the provided box.
Edit - Text boxes are provided for the five presentation data elements (how the patient presented, from where, with what complaint and what clinical intent; with optional indication of COVID-19 vaccination status).
Accept/Cancel - Buttons determine whether edits are saved or not.

Remember to refresh the source text after editing the structured data.

Problem Oriented Charting - Interactive Charting

Connect Care's problem oriented charting (POC) tools are "interactive", supporting "charting in place". Easily readable prose (e.g., "... presented from home (independent)...") is generated from structured data (e.g., "private residence, independent living"). The structured data, in turn, enables more accurate decision supports, disease management and reporting.

The key to interactive charting is to pay attention to the colour of the text font in reports, sidebars and documentation. Anything dark blue can be selected (clicked, tapped, etc.) to interact with the prose. The lack of underlining (a common way of signifying links) or other text decorations keeps the text compatible with external health information systems.

Typical interaction behaviours include rapid access to:

help, with pop-up links to definitions, explanations or additional instructions about the meaning of a section of documentation or how it is meant to be used;
information, with pop-up reports giving more detail or other information related to what appears in the source text;
editing, with pop-up editing tools (e.g., SmartForms, Flowsheets) that allow immediate modification of the data that shapes the source text; and
chart actions, with navigation to and opening of the part of the chart (e.g., activity, navigator, synopsis) containing the data informing the source text.

If in doubt... click. Activating a link or tool can do no harm. The best way to quickly habituate to the efficiencies of interactive charting is to select any (dark blue) text of interest. Remember to use the refresh icon if the source text does not immediately update after an interaction.

By not having to remember the diverse places where information is to be found or modified in a patient chart, interactive charting keeps the clinician in-the-flow while speeding up documentation tasks. It also promotes the use of structured data, with many resulting benefits.

ALERT: Once a note or document is signed, interactive charting links may still be active (e.g., to open sections of the chart) but the associated note text will not update, and no refresh tool is available to force an update. This is intentional! Signing a document locks in all its data, reflecting the state of the chart at the time of signing.

Problem Oriented Charting - POC Building Blocks

Both the problem oriented charting (POC) navigator and the POC sidebar show the current state of each of the main POC text building blocks. These are used in both progress and summative documentation (e.g., discharge summary). Additionally, the sidebar provides SmartLink mnemonics to help clinicians pull these blocks into personalized documentation.

Overview/Presentation

One sentence summary of patient context, reason for seeking help and reason for admission or consultation.

Patient Care Coordination Note

Care Coordination notes support patient-level longitudinal documentation about overall health status and how health problems relate to one another.

Hospital Course

This Wiki-like tool is used to record key developments occurring during a patient's admission. Resolved problems can be summarized alongside milestones in a course of illness. The Hospital Course is pulled into discharge summary templates.

Problem Notes

Each problem in the Problem List section supports one Problem Overview (succinct summary of key features of the problem for the patient, crossing all encounters), and one or more periodic Assessment and Plan notes to document progress.

Exceptional Care Plans

Patients may be on one or more integrative care plans that cross all encounters and detail how specific problems should be (urgently) managed by all disciplines in all settings.

Discharge Planning

This interactive text block summarizes key information about where a patient comes from, how their functional capacity may have changed and current destination plans.

History

Medical, Surgical, Family and Social History summaries help clinicians when problems are moved between the Problem List and Medical History instead of newly entered or resolved.

The content of the text building blocks can be edited using the POC Navigator. Alternately, the text is interactive and can be edited by selecting its subtitle or any blue text within.

Problem Oriented Charting - Using the POC Sidebar

An index, at the top of inpatient and outpatient chart sidebars, includes a "Problem Charting" (inpatient) or "POC" (outpatient) item. Selecting this opens a sidebar display of the current state of all problem oriented charting (POC) text building blocks.

Selecting the title or left arrow will open the problem oriented charting navigator (or problem list for outpatients) in the middle panel.
Embedded help is available when the help (?) link is selected. This will open a POC help guide in the sidebar. The help includes links to further assistance from the Clinician Manual.
POC text building blocks appear vertically, each revealing the current state of the respective structured data.

The POC sidebar can be used for a quick appraisal of the current state of shared documentation. It can also be used for interactive access to editing tools for changing that content.

Problem Oriented Charting - Finding POC Tools - Outpatient

Problem Oriented Charting (POC, poc.connect-care.ca) is supported by tools that help groups of clinicians maintain shared text blocks assembled to create standardized progress and summative documentation. One set of documentation tools supports POC during hospital encounters. Related but different tools are available during outpatient encounters.

For those new to POC, the best way to find the right tools is via the sidebar (right-most column of information in an opened chart) index (top of outpatient visit sidebar display).

Selecting the index label ("Problem Charting") opens the POC sidebar, which displays the current state of POC text (building) blocks.
Selecting the left-pointing arrow opens the outpatient problem list activity (with support for problem-based overview and assessment/plan notes) in the main (middle) panel of a chart.
Selecting the right-pointing arrow opens the problem list (with POC supports) in the sidebar.
Selecting the left arrow at the top of the POC sidebar section also opens the problem list in the main chart panel.

If the outpatient sidebar index is not immediately available, use the chart menu or chart search to find and activate the "Prescriber Sidebar".

For those committed to POC, personalize outpatient chart tabs to add the independent Problem List activity to be available by default when a chart is opened.

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