Difference between revisions of "V10 Note building basics"
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| − | Building notes is one of the most intensive parts of the implementation process. Fortunately, there are many resources to assist. Notes are unique in that each provider and user documents differently. One benefit of creating uniform notes across a site or organization is that documentation can become more standardized. Granted, note content and will still vary by the author, at least the data elements captured can be established and available as an outline. | + | Building notes is one of the most intensive parts of the implementation process. Fortunately, there are many resources to assist. Notes are unique in that each provider and user documents differently. One benefit of creating uniform notes across a site or organization is that documentation can become more standardized and reporting measures can become more consistent. Granted, note content and will still vary by the author, at least the data elements captured can be established and available as an outline. |
Revision as of 00:41, 23 March 2010
Building notes is one of the most intensive parts of the implementation process. Fortunately, there are many resources to assist. Notes are unique in that each provider and user documents differently. One benefit of creating uniform notes across a site or organization is that documentation can become more standardized and reporting measures can become more consistent. Granted, note content and will still vary by the author, at least the data elements captured can be established and available as an outline.
The steps of building a note in V10
1. Define Groups (whether they be by location, specialty based, or another strategy.)
2. Build note types/definitions in sa. Note types are high level descriptions of what the note will be designed for, for example and initial appointment, referral letter, or office visit.
3. Establish what sections are necessary for each note type. Sections include Chief Complaint, ROS, Histories, medications, etc.
4. Determine where text templates will be the best option. Text templates of other Touchworks users can be found in the clinical library.
5. Assign the text templates to the note section(s) and the Group(s) that will utilize the template.
6. When defining the note sections, each available note section will need to have a default action selected, whether that be cite Findings, Go To, Free Text, etc.
7. There are many other options that need to be designed and built into a note, but these are the general basic building blocks that will enable the Administrator to get notes into the system.
Basic Formatting of a Text Template
{{{Optional Text}}} - If no data is entered or selected within the triple brackets, the entire optional text is not added the note.
[ ] - Blank field for free text. Typically used in the context of a sentence or data capture where multiple choice does not make sense. For formatting, there needs to be a space between a bracket and the text inside the bracket.
[ text field ] - When selected, the text inside these brackets will be inserted into the note.