Note

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.

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

The concepts of Version 11 Note are described below.

DOCUMENT TYPE

• Term used in administrative workspaces
• Created in Document Type Dictionary (TW Set Up)
• 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)

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. dictate using dictation markers
4. 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.