V10 Note building basics

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Version Information

Description

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.

Strategy

Note Build Strategy


The steps of building a v10 note

  1. Define Groups (whether they be by location, specialty based, or another strategy.)
  2. Build note types/definitions in SA (V10 System Administrator). Note types are high level descriptions of what the note will be designed for, for example and initial appointment, referral letter, or office visit. An HTML document type must exist in the Document Type dictionary in order to link a note definition to it.
  3. Establish Note Definitions - what sections are necessary for each note type. Sections include Chief Complaint, ROS, Histories, medications, etc.
  4. Determine where text templates or Medcin templates will be the best option. Text and Medcin templates of other Touchworks users can be found in the clinical library.
  5. Assign the text or Medcin 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.

Carbon Copy Functionality

Carbon Copying the V10 Note