Note Definitions

Overview

A note definition in v10 of TouchWorks is the template for the overall outline and behavior of a structured note. Note definitions manage what note sections are available by default on the front end to the user and also help manage default relationships for Text Templates and Medcin Templates. A Note definition must be linked and based on a HTML document type. The descriptions used for note definitions must be unique within the group that the definition is being linked to.

Components

Note Sections

Note sections are the main building blocks to the note and give the note its sequential flow and general outline. There are many pre-delivered note sections that can be used in the note along with miscellaneous sections that can be renamed to better suit a specialized visit or component of a visit. The display function in the note definition is what causes the note section to appear viewable in the note workspace by default, however any not section can be engaged in the note workspace on the fly by clicking the Display All Sections button in the note workspace; click the Defined Sections button to return to only the sections selected to display by default for that note type.

Default Actions

One of the included benefits of using the TouchWorks Note (structured) module is the ability to take advantage of discrete instance data that has been entered and is being maintained in the EMR over time. Default actions are invoked by double clicking on the note section for which the default action has been assigned in the note definition. The intent or value added these default actions is to reduce the amount of dictation required by the provider and to automate anticipated functions in order to streamline the documentation process and reduce dictation errors.

NOTE: Most of the default actions available in the note module also exist as buttons in the note workspace. This offers some degree of flexibility or an ad-hoc workflow where needed.

Here are some examples of default note actions and section combos:

Note Section: Active Medications
Default Action = Cite
Result/Output = All entries from the Active list of the Rx module will be cited into the note section.

Note Section: Allergies
Default Action = Go To
Result/Output = Will automatically navigate the end user directly to the Snapshot workspace.

Note Section: Active Problems
Default Action = Add
Result/Output = The Add Problem dialog box will open in the note workspace allowing the user to add an active problem on the fly; this will populate both the active note and patient’s problem list.

Note Section: HPI
Default Action = Text
Result/Output = Will automatically launch the Text Input Dialog box. The user can then either select a text template that is associated with that note section from the list pane or directly dictate using Dragon.

Note Section: ROS
Default Action = Findings
Result/Output = Will automatically launch the Medcin template workspace allowing the user to use either the default Medcin template assigned to that note section or select from other Medcin templates that are associated with that note section.

Default T-Template

Most note sections available for use with note definitions are compatible and will allow the use of a text template. If desired a specific text template can actually be set as the default for a particular note section for that note definition. This might be practical in a situation where the note definition was created specifically to document a pediatric sick visit. In this case the provider might want to use the same physical exam text template every time.

When a default text template is set for a note section the user will see the text template already populated into the appropriate note section upon note initialization. A blue hyperlink will appear on the first word or characters in the template allowing the user to click the hyperlink and engage the text template.

Default M-Template

Very similar to setting a default text template certain note sections can also have a default Medcin template set. If the note section that has the default Medcin template also has a default action of Findings the user will be brought directly to the default template after double clicking on the note section. This might be useful in a situation where a provider is attempting to increase consistency in order to meet coding requirements and may want to use a template which will allow him/her to access a 10-point ROS.

Narrative vs. Bulleted Format

A note definition has the option to be set in one of two basic formats; narrative or bulleted format. These formats pertain to how findings and Medcin templates are rendered in the note. Bulleted renders in a basic bulleted list format while narrative uses some basic built in grammatical rules to generate statements.

Example: If a provider where to engage a HPI Medcin template and select “+” for the existence of coughing, wheezing, vomiting, and “-“ for abdominal pain; the outcomes would be similar to the following:

Bulleted:
• Coughing
• Wheezing
• Vomiting
• No abdominal pain

Narrative:
The patient has presence of coughing, wheezing, vomiting, and no abdominal pain.