2Structured Notes Objective Describe the key features of a structured note.Describe how to set default preferences.Identify which data will auto-populate versus manual entry.Describe how to create an acronym expansion.Identify how to assign for a co-signature.
3Advantages of Notes in QUEST Increased efficiency: Use of ‘copy forward’ like functionalityPulling data from other sources, e.g. VS, labs, meds, health issuesDrives compliance with key indicators – i.e. device medical necessityAccessible anywhere by all providersStandardizes billing and compliance language requirements
4Examples of Structured Notes Physician: Allied Health: H&P Event Note Progress NoteProcedure – Central LineDischarge NoteAmbulatory NotesAmb H&PAmb Well ChildAmb End of VisitAmb Follow UpAllied Health:Case Management NoteClinical Social Work NoteED Rapid Screening ExamProcedure – PICC InsertionPatient ProfileRespiratory Care NoteSpiritual Care NoteAmbulatory NotesAmb Intake NoteAmb Triage Note
5Navigating ToolsTo navigate through the content, there will be 3 navigational buttons located on the bottom left corner of the screen.= to return to the previous slide= to advance to the next slide= to return to the Table of Contents
6Table of ContentsUse the navigation button below or click a topic to proceed.How to Enter a NoteCreating a Preferred Documents ListBasic FunctionalityHow to Manage/ModifyPulling Data Into the NoteModifying Template“My Default” ExamAcronym ExpansionUse of Health Issues within the NoteAdding a Co-SignerChanging a Co-SignerAttending AttestationUnfinalizing a NoteConclusion
7Structured Notes:How to Enter a NoteTo access a structured note, first select a patient and then click Enter Document icon.
8Structured Notes:How to Enter a NoteType the first few letters of the document name to begin the search (no need to hit <Enter>).
9How to Enter a Note Once found, highlight the note and click . Structured Notes:How to Enter a NoteOnce found, highlight the note and click .
10Creating a Preferred Documents List Structured Notes:Creating a Preferred Documents ListNotes frequently used can be saved as a list of “personal documents.”
11Creating a Preferred Documents List Structured Notes:Creating a Preferred Documents ListTo create your list of Personal Documents:Select a patient.Select the Preferences Menu.Select Document Entry…
12Creating a Preferred Documents List Structured Notes:Creating a Preferred Documents ListTo create your list of Personal Documents: (cont.)Click the to open each sectionHighlight your note and click
13Creating a Preferred Documents List Structured Notes:Creating a Preferred Documents ListTo create your list of Personal Documents: (cont.)Now, go to the Browse Start Point tabSelect Personal DocumentsClick Set As Default
14Creating a Preferred Documents List Structured Notes:Creating a Preferred Documents ListBy setting Personal Documents as your default, Enter Document icon will always launch to your default view.
15Structured Notes:Basic FunctionalityAll structured notes have the same basic functionality:BLUE exclamation points ( ! ) are required fields to “complete” a note.RED asterisks (*) are mandatory fields to “save” a note.Multiple check boxes ( ) can be selected, but only one radio button ( ) can be selected per section.
16Structured Notes:Basic FunctionalityTo remove a selected radio button ( ), right-click and select Delete Data.If an option with an ellipse (…) is selected, additional data fields will appear.
17Structured Notes:Basic FunctionalityUse the navigation buttons to move between document sections, when available.or navigates to the next or previous section.or navigates to the first or last section of the structured note.
18Structured Notes:Basic FunctionalityAnother way of navigating within the note is to hover the mouse over the Sections tab, located at the top-left corner.Click the and select the specific section you would like to view.
19Structured Notes:Basic FunctionalityMost structured notes have the current Date and Time auto populate upon opening.Make sure your name appears in the Accessing Provider field.
20How to Manage / Modify Structured Notes: Structured notes have a 20 minute lock-out feature to prevent concurrent charting.There is a potential to lose unsaved data beyond this time.When all “required” and “mandatory” fields are filled, the note can be saved as complete or final.Notes that require a co-signature can only be saved as incomplete.Once the note is co-signed, it can be saved as final.
21How to Manage / Modify Structured Notes: Whenever given the option, Submit as Final is the preferred method of saving.Final Documents cannot be modified. Free Text notations may be added using the “Append” function.
22How to Manage / Modify Edit saved notes within the Documents tab Structured Notes:How to Manage / ModifyEdit saved notes within the Documents tabFirst, highlight the note. Then right-click.Modify Document – to edit a complete or incomplete note.Cancel Document – to delete a note entered in error. This will display as a lined out item and cannot be reinstated.Append Document – to add documentation to a finalized note.
23Pulling Data Into the Note Structured Notes:Pulling Data Into the NoteThe Preview tab is to view the note in its entirety.The Preview option displays in real time, which can be used to review the note during documentation and prior to saving.
24Pulling Data Into the Note Structured Notes:Pulling Data Into the NoteNotes may contain “pull sets” that retrieve data from other applications. Only selected checkboxes of a “pull set” will populate the note. Below is an example of a “pull set.”
25Pulling Data Into the Note Structured Notes:Pulling Data Into the NoteIf pull set data need to be changed, use the application icons (examples below) to update the patient information while in the note.Otherwise, erroneous data will always exist.
26Pulling Data Into the Note Structured Notes:Pulling Data Into the NoteIf needed, click the Refresh icon to populate the pull set with the updated information.
27Pulling Data Into the Note Structured Notes:Pulling Data Into the NoteNotes may also have medical logic modules (MLMs) that allow data to populate your note. An example is lab results.Some MLM text fields will allow for information to be added or deleted.
28Pulling Data Into the Note Structured Notes:Pulling Data Into the NoteSome MLMs are on-demand options.Select the radio buttonCheck mark the info to populate the noteClick OK
29Structured Notes:Modifying TemplateNotes may provide options for documentation preference. An example is shown below:Physical exam by individualized systems (default)Physical exam (free text)
30Structured Notes:Modifying TemplateBefore documenting on the note, select Modify Template.The template can only be modified when data do not exist in the section that will be modified.
31Structured Notes:Modifying TemplateChoose your documentation preference and deselect the other:Physical exam by individualized systems (available as default)Physical exam by all systems (free text)
32Structured Notes:Modifying TemplateAfter making your choice, check mark Save template for me and then click OK.This recalls your setting every time you open the note, regardless of the selected patient.
33“My Default” Exam Structured Notes: When the option Save as Default is available, create your default information first. Fill out each text field for that section. Then save it as your default.Physical exam by individualized systemsPhysical exam by all systems (free text)
34“My Default” Exam Structured Notes: SUGGESTION: Retrieve your “default exam” or “my last exam for patient” before entering any free text. Otherwise, the free text will be overwritten.Physical exam by individualized systemsPhysical exam by all systems (free text)
35Structured Notes:Acronym ExpansionBecause structured notes have text fields, using Acronym Expansion can be helpful.To setup your acronyms, select Preferences > Acronym Expansion.
36Structured Notes:Acronym ExpansionClick Add to create your own acronym or click Import From Other User.
37Acronym Expansion In the Acronym field, type an acronym. Structured Notes:Acronym ExpansionIn the Acronym field, type an acronym.It is suggested to begin some acronyms with a period (.) to prevent unintentional acronym expansion.In the Expanded Text field, type the full text of the acronym.Click Apply to create more acronyms.
38Structured Notes:Acronym ExpansionWhen importing from another user, use the dropdown list or type a person’s last name.
39Structured Notes:Acronym ExpansionPlace a checkmark next to the acronyms you would like to import and then click OK.
40Structured Notes:Acronym ExpansionREMINDER: Acronym expansion is case sensitive. For example, “bid” will not expand to “twice a day” because the acronym is in caps.
41Use of Health Issues within the Note Structured Notes:Use of Health Issues within the NoteHealth Issues management can be done from within a note by clicking the Health Issues icon.
42Use of Health Issues within the Note Structured Notes:Use of Health Issues within the NoteDrag and drop the order/medication on top of a health issue in the Problem List.
43Use of Health Issues within the Note Structured Notes:Use of Health Issues within the NoteThe order/medication will not associate if dropped in a blank area.Blank Area
44Use of Health Issues within the Note Structured Notes:Use of Health Issues within the NoteCheck mark Include Linked in order to associate an order/medication to multiple health issues.
45Use of Health Issues within the Note Structured Notes:Use of Health Issues within the NoteSingle click in the text box to document your Assessment and Plan for each Health Issue.
46Use of Health Issues within the Note Structured Notes:Use of Health Issues within the NoteTo take out data entered in error, remove the check mark.
47Adding a Co-Signer To assign a note for co-signature: Structured Notes:Adding a Co-SignerTo assign a note for co-signature:Select the Document Info tabThen check mark the Co-Signer checkbox
48Structured Notes:Adding a Co-SignerSelect the co-signer’s name from the list of available current providers.
49Adding a Co-Signer Structured Notes: If the co-signer’s name is not listed:Delete the name in the Care Provider field.Type the co-signer’s name.Click Search.If multiple names appear, select the correct name.TYPE NAME HERE
50Structured Notes:Changing a Co-SignerIf the designated co-signer needs to be corrected, it can be changed using Signature Manager.If the icon is not readily available, you can use the menu option Go To > Enter/View > Signature Manager.
51Changing a Co-Signer Structured Notes: To change the co-signer through Signature Manager:Change Provider Selection to Selected Providers.Click the ellipsis (…) to search for the co-signer’s name who was identified in error.Narrow the Item Type Filter to “documents” only.Select Reassign.Click Get List.
52Changing a Co-Signer Structured Notes: To change the co-signer through Signature Manager (cont.):Check mark the note that needs to be re-assigned.Click Reassign.
53Changing a Co-Signer Structured Notes: To change the co-signer through Signature Manager (cont.):Click the ellipsis to search for the correct co-signer.Enter the reason for re-assigning to a new co-signer.Click OK.
54Attending Attestation Structured Notes:Attending AttestationBilling Service Level and Attending Attestation sections of a note are for Attending use only.
55Attending Attestation Structured Notes:Attending AttestationThe Attending Evaluation Date/Time is a manual entry for when the Attending does the attestation.
56Attending Attestation Structured Notes:Attending AttestationAttending Attestation: Provide Attending attestation statements for different scenarios; additional comments as appropriate.
57Attending Attestation Structured Notes:Attending AttestationWhen the Attending is ready to finalize the note, select Note Finalization.Once finalized, the note cannot be modified.
58Structured Notes:Unfinalizing a NoteIn the event a note was finalized in error, only the Attending can unfinalize that note.Notes can be unfinalized on “active” visit accounts only.Visit accounts are no longer active after 14 days post discharge.
59Unfinalizing a Note To “unfinalize” a note: Structured Notes: Highlight/Select the noteRight-clickSelect Unfinalize Document
60Unfinalizing a Note To “unfinalize” a note (cont.): Structured Notes: Answer the prompt.Then right-click again on the note to modify.
61Structured Notes:Unfinalizing a NoteWhen re-finalizing the note, notice that Note Finalization is already marked.You must uncheck Incomplete in order to save and finalize.
62Structured Notes:ConclusionFor issues with a structured note, contact the Help Desk at (714)
63Conclusion You have reviewed: The functionality of a Structured Note. Structured Notes:ConclusionYou have reviewed:The functionality of a Structured Note.How to create acronym expansions.How to designate a co-signer.How to modify your template.How to set your default preferences.How to re-assign to the correct co-signer.
64You have completed the course. Structured Notes:ConclusionYou have completed the course.DISCOVER ● TEACH ● HEAL