Note

Allscripts Enterprise Note

Enterprise Note module is a web based tool for clinical note creation, inbound transcription, direct dictation, structured data entry, correspondence management and automated efficiency. A medical note, or electronic medical note, contains all relavent, free form information as it pertains to an encounter between a medical provider and patient.

Benefits of the Note module are; use of knowledge based structured templates and the ability to add textual data as needed, increased turnaround time of documentation, reduction in overhead cost for transcription services and increased revenue as a result of better documentation.

See Carbon Copy to set up this functionality for your notes.

Description

The Note module of Allscripts Enterprise EHR Version 11 replaces the note definitions of Version 10 with note templates. Depending on how the note template is configured, appropriate sections, text templates, note forms, lists and results can automatically populate the note . Note functionality is managed from the Note Admin workspace.

Concepts of AEEHR Version 11 Note

DOCUMENT TYPE

• Term used in administrative workspaces
• Created in Document Type Dictionary (TWAdmin Workspace)
• Links to:
  • Note input templates
  • Note output templates
• Used when defining auto-print defaults
• Displayed in ChartViewer on Clinical Desktop as labels for output documents generated by Note module

NOTE INPUT TEMPLATE

• Term used in administrative workspaces
• Determines contents that are displayed in NAW
• Each is linked to a document type
  • Document type appears as choice in Visit Type list in the Note Selector. The Visit Type:
    • Is selected by provider
    • Determines which note input template populates the NAW. Based on provider specialty, patient sex and age.

NOTE OUTPUT TEMPLATE

• Term used in administrative workspaces
• One input template can be linked to many output templates

VISIT TYPE

• Term used in application, not used or referenced in administrative workspaces in reference to Note module
• User selects Visit type from Note Selector
• Corresponds to a note input template based on specialty, patient sex and age
• Can create parent and sub-visit types

NOTE FORMS

• Term used in both administrative workspaces and referenced in application (users select & add forms from NAW)
• Built using Note Form Build tool
• Allscripts delivers
• Can include Medcin findings, Text, Illustrations, Pictures and Text Templates
• Displayed in body of NAW
• Defined and linked to note sections (HPI, ROS, PE, etc)
• Editing Note Forms

NOTE AUTHORING WORKSPACE (NAW)

• This is a workspace in the application where providers document the patient visit
• Possible entry methods:

1. type free text
2. dictate free text using Dragon
3. select preconfigured items from note text templates
4. dictate using dictation markers
5. select preconfigured items from note form

• Once entered, system formats the information into one or more output documents. These documents appear in ChartViewer and can be printed and faxed.

PREFERENCE SETTING REQUIRING PASSWORD WHEN SIGNING NOTE

• Under general Preference Settings there is a preference "Order Authentication TimeOut"
• See .NET Preferences for more details.
• What this means is: If the authentication time out has been set at 5 minutes. This means that if a provider signs a note, enters their password then creates a second note and signs it within 5 minutes they will not be required to enter their password on the second note.

CONSIDERATIONS BEFORE NOTE IMPLEMENTATION

• Have detailed workflows been documented based upon Certified Workflows?
• Is the patient banner configured to show the note button?
• Have the Note Workspace Views been assigned to end users?
• Have all document types been assigned to sections in the chart viewer (done from Chart Admin)?
• Is Carbon Copy set up for specified outputs if necessary?
• Are Auto-print Defaults set up for specific outputs?
• Will existing document templates(document admin) be sufficient for note outputs or do modifications need to be made or new document templates created?
• Do users understand the difference between problem driven and chief complaint driven notes?
• Are the most common chief complaints activated?
• Who will have the security to Invalidate notes and manage note locks? What will this process look like?

FOR PHYSICIAN ASSISTANTS OR MID-LEVELS WHO NEED TO HAVE THEIR NOTE SIGNED

Setup:

• PA's finalization authority must be lower than the document type finalization authority.
• In the document type dictionary under the "General Properties II" a check mark needs to be placed on "Prompt User to Route for Further Signature" to be used for PA's.

Workflow:

• PA creates note, signs note as author
• Task window prompt appears for PA to send a "co-sign" note task to provider. This allows the flexibility for those PA's who may alternate which physician they have co-sign their notes.

For more details: Force User to Send the Note for Attending Physician Signature

Note Questions and Answers

• Batch Sign Enhancements 11.1.7
• Note Sections: Input vs. Output
• Expanded Details
• Extracting Notes from SQL Server Management Studio
• Note icon not appearing on the Schedule

Back to: Beginner's Guide to Allscripts Enterprise EHR.