257H Progress Note Templating Beyond the Basics

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257HProgress Note Templating Beyond the
Basics

• Vicky SoulierClinical Applications
  CoordinatorMpls. VAMC
• John ReiffenbergerClinical Applications
  CoordinatorBlack Hills Healthcare System

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Reasons For Using Note Templates

• Templates prompt for necessary information to
  reduce errors of omission
• Help speed up note entry
• Produce notes with a predefined layout for easier
  reading
• Templates help reduce spelling errors
• Templates reduce the use of unapproved
  abbreviations
• Improve documentation for billing and JCAHO
  requirements
• Patient information is inserted automatically
  into the note

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Objective

• Demonstrate Export Import functions to share
  templates
• Demonstrate adding additional template fields
  data objects into imported
  template
• Demonstrate adding additional "sub templates"
• Understand what Health Summary Objects are and
  how they are created through Text Integrated
  Utilities (TIU) Health Summary Object
• Create Template Fields-
• Edit Template Fields option in CPRS
• Access controlled by parameter TIU FIELD
  EDITOR
• CLASSES

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Template Types

• Templates-
• Contain text and objects that can be placed
  into a progress note
• Folders-
• Used to organize templates dialogs
• Group Templates-
• Pulls ALL templates within the group into
  the progress note
• Contain predefined text, template fields and
  data objects
• Dialogs-
• Allows multiple templates to be placed under
  one header
• Only pulls in the SELECTED templates into
  the progress note
• Also contain predefined text, template
  fields and data objects
• More selection options than with templates
• Reminder Dialog-
• Automatically inputs text into the
  progress note
• Passes codes to Patient Care Encounter
  (PCE)
• Allows placing of orders within the
  template without waiting
• to go to a separate order screen

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Patient Data Objects

• Imports patient data from other VISTA packages
  into the progress note
• Examples include recent meds, vitals, lab
  results, patient demographics, date and time,
  etc.
• brackets are used to identify "Objects"
  within the template

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Text Integrated Utilities (TIU) Health Summary
Objects

• Allow for the creation of objects that import
  patient data into the note from components
  available in the Adhoc Health Summary Report
• Examples include radiology impressions,
  allergies, progress notes

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Template Field Types

• Edit boxes-
• Allow control over the length of the
  entry
• Combo boxes-
• Drop down boxes with predefined text
• Buttons-
• Work like toggle switches
• Check boxes-
• Allow for multiple selections
• Can be either vertical or horizontal
• Radio buttons-
• Allow for only one selection
• Can be either vertical or horizontal

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Template Field Types continued

• Date-
• Six Date Types
• - Date
• - Date Time
• - Date Required Time
• Number-
• Allow control over a range of numbers
• Hyperlink boxes-
• Allow links to web sites or documents
• Word Processing-
• Allow control over the width and number of
  lines
• Text-
• Allow free text entry (good for Display
  only such as instructions)

- Combo Style - Comb Year Only - Combo Year
Month
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Template Field Properties

• Template fields can be set to be
• Required
• Template fields can be set to be
• Display Only
• brackets are used to identify
• Template Fields" within the template

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Example Template display in CPRS note
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Lets Go! SIGN ON TO CPRS

• Find your student number by your
  computerClick this Icon
• Access Code VEHU
• Verify Code VEHU
• Your patient isltyour number spelled outgt,patient
• Your Signature Code VEHU

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Practice Exercise

• Create a template field that has check boxes for
  the following items
• weakness
• tremors
• memory loss
• headache
• dizziness
• numbness
• mood changes
• suicide thoughts

• Add a sub-template to the Review of Systems
  template we just worked on
• Name the template ROS-NEURO, like we did for
  ROS-LUNGS
• Create a sub-template under ROS-NEURO, name it
  Abnormal and add the text Patient complains
  of then add your new template field
• Create another sub-template under ROS-NEURO and
  name it Normal and add the text Patient does
  not complain of and add the template field you
  just created

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Questions?