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Patient Notes

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Patient Notes PCS Lesson Six Objectives Identify when a patient care note is needed Create and amend a patient note View existing notes Create a canned text note When ... – PowerPoint PPT presentation

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Title: Patient Notes


1
Patient Notes
  • PCS Lesson Six

2
Objectives
  • Identify when a patient care note is needed
  • Create and amend a patient note
  • View existing notes
  • Create a canned text note

3
When do you write a patient note?
  • Patient notes should be written
  • Upon admission, transfer, or discharge
  • Any time your patient has a change in
  • status
  • Any time an unexpected event occurs
  • (For example a fall, anxiety attack, etc.)
  • If you cannot find an appropriate
  • intervention to document on

4
  • The first step when writing a note is
    selecting the correct patient. We will click on
    the PCS Worklist icon now to access our list of
    patients.

5
  • The patient we want to write a note on is
    Mrs.
  • Red. We will click on her name now.

6
  • Once your patients name is highlighted,
    you can click on the Notes button on the right
    side of the screen.

7
  • This is the Patient Notes screen. It is
    where we enter, view, and edit patient notes. We
    will start by reviewing the different sections of
    this screen.

8
  • The three buttons at the top of the screen
    allow you to choose the function you want to
    perform. You can roll your mouse over each button
    to see what its function is. E stands for Enter,
    A stands for Amend, and V stands for View.

9
  • Before you enter a note on a patient, make
    certain you have selected the correct patient by
    checking the information in the middle section of
    the screen. Notice that your user ID is also
    found here.

10
  • The lower portion of the screen will detail
    the previous notes entered for this patient. The
    Category column shows which discipline entered
    the note

11
  • There is also a Date/Time/User column that
    will show when the note was written and the
    initials of who wrote the note.

12
  • The Note text column will show the first
    line of text in the note. You will not see the
    entire context of the note here.

13
  • The Edit column will show if the note has
    been changed. If someone has edited the note, the
    letter Y will show up in the edit column.

14
  • Our patient has experienced dizziness and
    shortness of breath that required a call to her
    physician. We need to document the details of
    this event by entering a new note. To enter a new
    note, we will click on the E button.

15
  • This will open the screen where we will
    type our patient note. The patients name, along
    with the date, time, and authors name will
    appear at the top of the screen. If you need to
    change the date or time for a note, you can click
    in the appropriate areas at the top of the screen
    and make the changes.

16
  • The cursor will be blinking in the Enter
    Note Links box. We will press the enter button on
    our keyboard or click in the large white Note
    text box at the bottom of the screen.

17
  • The note text box is where we will begin
    typing our note. You can use the backspace and
    delete keys to make changes. At the end of a
    line, the text will automatically wrap around to
    the next line for you.

18
  • Here we have entered a note documenting our
    patients change of status. When you are finished
    typing your note, you have to save it. To do
    this, we will click on the green check mark in
    the upper right corner of the notes screen.

19
  • You will then confirm that you want to
    File, or save the note by pressing the Yes button.

20
  • You can now see the new note added to the
    list on our screen. The most recent note will
    appear at the bottom of the list.

21
  • Now that you know how to enter new notes,
    lets learn how we can make corrections to notes
    we have already saved. We will use the Amend
    button for this.

22
  • We now realize that the final oxygen flow
    for our patient was 1L, not 2L as we documented
    in our note. First we must click on the note we
    wish to change. It will become highlighted, as we
    see on our screen here.

23
  • We will now click on the A button to Amend,
    or change, or note.

24
  • This is the Amend Note screen. It looks
    very similar to the Enter Note screen, but has a
    special section at the bottom called Note
    Addendum where we can enter the changes to our
    note.

25
  • Just as you cannot white-out or scratch out
    a note entered on a paper chart, you cannot
    delete the contents of previous notes from the
    computer. We will change our note by typing in
    the Note Addendum section of the screen. We can
    use the Enter key or the mouse to click on the
    Note Addendum section so we can begin typing.

26
  • We have now entered our correction to the
    note. We will File our change by clicking on the
    green check mark.

27
  • Once again we will click on the Yes button
    to save our changes.

28
  • Now that we have amended our note, we can
    see a Y in the Edit column.

29
  • GBMC has built some pre-written notes into
    Meditech that you can use to document certain
    situations for your patient. These notes are
    called canned-text notes. A canned text note will
    have the outline of the note created for you and
    all you must do is fill in a few blanks and your
    note will be complete.

30
  • To use a canned text note, we will click on
    the E button, just like we did to enter a new
    note.

31
  • Lets click on the Note Text section of our
    screen to get started.

32
  • To enter a canned text note, you must push
    two buttons in sequence. First, we click on the
    F5 key of our keyboard. This will tell Meditech
    to get our note. Lets see what this does.

33
  • The F5 button opened the Get window for
    us. Next we have to look up which canned-text
    note we want. We will use the lookup key F9
    to bring up a list of available notes.

34
  • These are some of the available notes we
    can choose from. For practice, we will create an
    Admission note. To select a note, we click on it
    to highlight it and press Enter or the green
    check mark. We will do that now.

35
  • A standard admission note will appear.
    Notice the note has pulled in your patients
    name, age, physician, and diagnosis. The cursor
    will be blinking in the first place we need to
    fill in information. For this note, it happens to
    be after the word from, so we will fill in where
    the patient came from.

36
  • We have entered ED because our patient
    came to our unit from the Emergency Room.
    Whenever we see brackets in a canned text note,
    it means that is information you will have to
    fill in. We can see our next set of brackets
    after the word unit, where will will specify
    which unit the patient was admitted to. To
    advance to this next set of brackets, we can use
    the Esc key. Lets do that now.

37
  • We have been advanced to the correct place
    and filled in our unit number. We will now press
    the Esc key again to move to the next space we
    need to document.

38
  • The next piece we need to fill in has
    selections we can choose from. The selections are
    at the top of the screen and the actual note text
    will be on the bottom of the screen. The patient
    was transported via stretcher, so we will click
    on Stretcher and press the Enter key or click on
    the green check mark.

39
  • Now we are at the last place where we have
    to fill in information We will type in spouse.

40
  • Now we are finished filling out our
    canned-text note. To deposit this note into the
    Note text portion of our screen, we will click on
    the green check mark.

41
  • The note is now in the Note text portion of
    the screen. We can make any additions or changes
    here before we File. We are happy with the note
    we have entered, so we will use the green check
    mark to File our note now.

42
  • We will select Yes now to
    save our note.

43
  • Canned-text notes can be a quick way to
    document notes in Meditech. If you have any ideas
    for canned-text notes that may be useful to you
    or others on your unit, pass the idea on to your
    unit supervisor/manager. We can add more
    canned-text notes at any time.

44
  • We will now learn about the last button at
    the top of our screen V for view. Lets view
    the note we previously edited. To do this, we
    must first click on the Note, which we will do
    now.

45
  • Now we are ready to click on the V
    button. We will do this now.

46
  • The view function shows the detail of the
    note, including any amendments or changes that
    were made to the original note. Here is what our
    amended note looks like.

47
  • Notice that our original note appears
    first. We can also see our addendum at the bottom
    of the screen.

48
  • Keep in mind that the View button is only
    for viewing notes not for entering new notes of
    making changes. To close the view note window, we
    will click on the Red X.

49
  • This has taken us back to the main Patient
    Notes screen. To exit back to our status board,
    we must click on the Red X again.

50
  • We will click
    on Yes to exit.

51
  • We can also view notes in the EMR/Open
    Chart. Lets click on the EMR button to see where
    we would do this.

52
  • Now we are in the EMR for our patient. We
    will find our notes by clicking on the Notes
    button from the right side menu.

53
  • This will open the Notes screen where it is
    possible to view the notes entered by all
    disciplines who document notes in PCS. To view a
    note, we can click on the blue information icon
    at the end of the row.

54
  • For more detailed information on how to
    view and navigate in the notes section of the
    EMR, please review the EMR/Open Chart tutorial.

55
Summary
  • You will enter patient notes on admission,
    transfer, discharge, with change of patient
    status, or if an unusual event occurs that you
    cannot document on a regular intervention.
  • To change a note, use the A button for Amend.
  • You can view notes by using the V button or in
    the notes section of the EMR/Open Chart.
  • Canned text notes are pre-built notes for ease of
    use. Use F5 then F9 to open the canned-text note
    menu
  • Use the Esc key to move to the next section of
    the canned text note
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