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Electronic Progress Notes

Page history last edited by Kendall Rogers 9 years, 11 months ago
Please open the progress note template copy it into an autotext template for your progress notes.  Start a new note everyday, do not copy the previous days note, read below for quick tips with this.  Our goal is to have all notes following the same format - let me know if you have recommendations for changes to the template to improve it.  Thanks! 
 

~ Entering Inpatient Progress Note ~

 

 

  1. Click Clinical Notes tab. 
  2. Click Add document icon.
  3. In Type field click drop-down arrow, and then choose Inpatient Provider Progress Note (consultants should use Consult - (your specialty here)).

Note: If Progress Notes is not displayed, close drop-down menu and right-click.  Point to Document Type List and then choose Complete.  Repeat Step 3.

  1. Click Insert Template icon. 

  2. In Associated templates field, double-click the template you wish to use.

You can import labs, medications, and HPI

                    Vitals can be copied in off of the daily rounds summary

 

  1. Repeat for each additional template to be inserted.

Note: Once template(s) are chosen, auto text or regular text can be added before signing.

 

 

  1. Click Sign when finished.
 
 

Other Time Saving Tips

1. To set "Inpatient Provider Progress Note" as Default so you do not have to choose it when starting a note:
 
Open Powertchart, click "menu" tab on left, and select clinical notes.
On top menu bar select 'Documents', then click on 'Options'.
Dialog box will open; in the drop-down menu at the top find "Inpatient Provider Progress Note" and select it.
Click OK. (Changes will not take effect until you close and re-open Powerchart)
 
  
2. To limit the number of document types or to add other types of notes to your default list (clinic note, inpatient provider note, code note, procedure note, etc...):
 
Find the note type you want to add in the left column and double click it, it will show up on the right column
Delete any notes from the right column by double clicking them that you do not want showing up
Repeat for all the notes types you want (recommend inpatient provider PN, procedure note, and code status)
Click OK (Changes will not take effect until you close and re-open Powerchart).
**Go onto next step before closing this box, start with step 3 below**
 
 
3. To set folder options so that Progress Notes or Consult Notes are automatically expanded in the folder list (this allows you to see all notes without having to double click the folder and sub-folders):
 
Open Powertchart, click "menu" tab on left, and select clinical notes.
On top menu bar select Documents, then click on options.
Dialog box will open; click on "Index defaults" tab.
Double click the folder types you want auto-opened to move it to the right column (consult note, inpatient provider progress note, interim summary-adult, imported TEE, Discharge Summary-adult, etc...)
Click OK. (Changes will not take effect until you close and re-open Powerchart).
 
 
4. Preparing for rounds efficiently in the early AM:
 
From the "all results flowsheet" for a pt (default page when looking up ap patient), open the previous day's Inpt. Provider Note.
Right click in note and click "Add". Start your new note by autotexting in your progress note template (start a new note everytime, do not copy and paste entire previous days note.) 
Highlight and copy the ID (or insert the HPI rubber stamp to import hand-off sheet HPI), A/P, and Hospital Issues from the previous day's note and paste them into the new note. Stamp labs and meds into your new note.
Save and close the note, select open now option and then print... take these with you and fill in the vitals, PE, and changes to the A/P.  Present off of these notes with access to previous days plan.  Open the saved note later and modify as needed, be sure to change the A/P and do not only add to it. (note: you still have to review labs not on the progress note like blood/urine culture results and f/u on studies - you can do all of this from the daily rounds summary view).
 
 
5. Editing or changing an existing Autotext template using the same name:
 
Open a new note and insert your existing autotext into it
Hit button that states 'manage autotext' right next to rubber stamp button
Double click the autotext name in bottom table to make it active, then hit the delete button
Click Close and return to your note and edit the text any way you need to
Select all of the text, right click, and save it as autotext with the same name that you just deleted 
 
 
 

Other Tips for Consultants:

Use Care Teams

List under consult notes

 

 

 

 

 

 

Comments (1)

Lenny said

at 10:03 am on Oct 1, 2009

This page changed my life!

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