Notes

15. Clinical Notes (PowerNote)

Basics
Use Clinical Notes to document the patient encounter and create an electronic
record of that encounter. Clinical Notes allows you to complete an entire patient
encounter, including writing documentation, reviewing results, assigning a
diagnosis, and placing orders by using PowerNote.

Features of the PowerNote include:

Immediate availability of posted information.

Sort documents by author, date, encounter type, note type, and note status.

Accurately capture edits and addenda to documents. The original document

remains preserved with an unlimited number of corrections and emendations
attached to it.

Visual alerts in both icon and alphanumeric form show providers when
clinical results are available in the system.

Note: Remember to use the Refresh button frequently.

Creating a PowerNote starts with selecting an encounter pathway, which is

designed for a single, specific reason for encounter. The encounter pathway then
expands to display all the elements of the diagnostic exam, from the symptoms of
the present illness to treatment plans and a final diagnosis (including ICD-9
billing codes). The encounter pathway serves as a template, with data based on
best practices, enabling the healthcare provider to focus on questioning, the
examination, and overall patient evaluation

PowerNote Overview
Before generating a new PowerNote, familiarize yourself with the general
features of the PowerNote so that you understand its capabilities.

PowerNote Organization
A PowerNote is organized into two sections: the Navigator and the PowerNote
Documentation Area.

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 Notes

Navigating PowerNote
After selecting the Clinical Notes section from the chart menu, Clinical Notes is
organized into a navigator pane on the left, listing the notes available, and a
PowerNote workspace on the right.

PowerNote Navigator

The navigator organizes the sections of the selected PowerNote, called

paragraphs. The paragraphs are listed in a tree in the navigator. Click the plus
sign next to a paragraph to reveal the available sections of information, called
sentences. To navigate quickly throughout the note documentation, click a

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Notes paragraph or a sentence within the navigator to link you directly to that item in
the documentation area.

PowerNote Documentation Area

Complete your patient notes in the PowerNote Documentation Area.

Select a PowerNote
To start your note, click Add from the Clinical Notes section. Then you can
search for the type of PowerNote template relevant to your encounter by using
any of these quick ways to search.

Note: Notes in FirstNet will continue to pop-up suggested note based on

the nurses selected reason for visit.

Select by Encounter Pathway

Encounter Pathway allows you to search for notes with restriction capabilities of
Associated Diagnosis and Note type.

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 Notes
Select by Existing PowerNote
Start a PowerNote by basing it on a note you previously saved or signed.
Options exist for viewing notes from the current encounter or all encounters.
There is also an option for viewing only your notes. You also have the ability to
see only unsigned notes. You can finish notes that are in a saved status and sign
them, or you can copy a signed note to a new note and edit the new note that is
created by this action. If there is the need to delete a saved note, it can be done
from this tab.

Select by Precompleted PowerNote

If you create your patient notes using a consistent style or format, you can save a
note as a Precompleted note and use this note format from one patient to the next.
You can select whether you would like to see only your Precompleted notes, or
the Precompleted notes that are shared across the organization. Remember to
change or edit the date, time, and other patient-specific information when using
Precompleted notes.

Select by PowerNote Catalog

Start a new note by selecting a template from the PowerNote Catalog. Notes
found in the Catalog tab are referred to as encounter pathways.

Select by Recent PowerNote

This option displays the most recent notes that you have accessed, either through
the care design or from the Precompleted notes list. The most recent note you
have used is listed at the top.

Select by Favorite PowerNote

When you add a PowerNote to your Favorites, you can easily find the note by
searching your Favorites.

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Notes Auto Populate a PowerNote
PowerNote is powered with the ability to automatically populate your note with
patient information pulled from documentation completed earlier in the
encounter. Based on the content of the particular type of PowerNote you select,
such as a Physician Progress Note or specific Procedure Note, automatic
population can automatically add the following pieces of information:

Chief Complaint

Allergies

Medication

Problems

Past Medical History

Family History

Procedure History

Vital signs from the flowsheet

Measurements from the flowsheet

It is completely your decision whether or not to automatically populate a new

note.

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 Notes
View Sentences In PowerNote
The right-facing double arrow next to each sentence enables you to expand
the sentence to reveal additional terms. The left-facing double arrow enables
you to collapse the sentence to hide the expanded terms.

Use Mouse for Data Entry in PowerNote

Your mouse is the main tool for data entry in the PowerNote. By positioning the
pointer over a term, you can perform the following actions:

Click a term once so that term is displayed in your final signed

note.

Click a term a second time to chart a pertinent negative

so the negative is displayed in your final signed note.

Click a term a third time to clear the selection.

Note: If you decide that you do not want to document anything for a
particular sentence, right-click the sentence and clear the sentence.
Doing this removes the heading from the text summary.

Add Comments to Terms in PowerNote

You can add comments to a term in your note by peforming the following
actions:

1. Right-click the term and select Comment.

2. Enter the comment, and click OK.

3. The comment is displayed in parentheses within the note.

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Notes In addition, you can enter comments in any sentence that has the term Other as
an option. For example, when completing Review of Symptoms, selecting the
finding, Cardiovascular Other, opens a text box allowing you to enter your
comments accordingly.

View Paragraphs in PowerNote

Hide or reveal whole paragraphs within the note Documentation Area using the
Hide Structure or Show Structure link.

This can be very useful in organizing the note. If you hide the structure of each
paragraph once you are finished you will see what it will look like in the actual
note and be able to tell you are finished.

Free Text in PowerNote

To enter free text into a paragraph structure, select the Use Free Text link to
activate a free-text cursor within the paragraph.

Note: Use Free Text should be used by all clinicians to tell the story for
History of Present Illness (HPI).

Insert Sentences in PowerNote

Sentences can be added to a note by using the Insert Sentence function. This
allows you to add documentation without the need to create an additional note.

1. Right-click the paragraph name in which you would like to insert a sentence,
and select Insert Sentence from the menu.

2. A list of available sentences opens. Click a wanted sentence from the list to
insert into your note. Click OK.

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3. The inserted sentence is circled to indicate that it is an inserted sentence. Notes

PowerNote Symbols Indicate Special Action

Triple Bar Symbol (===)
Some terms have the symbol, = = =.

This symbol indicates that this term requires data to be entered when selecting it,
such as a date or number.

1. Click the data entry term, = = =.

2. Enter your data.
Note: Date terms default to todays date.

3. Click OK when done.

Plus Symbol (+)

Some terms have a plus sign (+) at the end of the word. The plus indicates that
there are additional details you can document for this term, but they are visible
only if you click the term with the plus sign. This is an illustration of a
Laceration Repair sentence:

Asterisk Symbol (*)

Some terms are repeatable or automatically repeat. This allows you to document
the data for multiple occurrences. For example, if your patient received chest
tubes in five locations, you need to document all five. To do this, click the
asterisk (*) to add additional chest tube terms so you can document specifically
about each one.

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Notes
Ellipsis Symbol ()
Content is displayed in the note for documentation. If there is additional content
you notice an ellipsis () after the entry.

Click any of the ellipsis to bring up the additional data relevant to the term.

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Effective date: April 18, 2011 Version 1 Tracking Number: 25TRGEXT019862
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