4 - Get Started with your own documentation

 

The following are some initial types of work flows for learning purposes.

Starter Shortcuts:

Subjective:         Sub-       Sub=     Sub?
Objective:           Obj-       Obj=      Obj?
Assessment:       Ass-      Ass=      Ass?
Plan                     Pla-       Pla=       Pla?
Medications:        Med-      Med=      Med?
Follow Up:            Fol-      Fol=        Fol?

Active Problems:    Act-      Act=       Act?
Surgeries             Sur-      Sur=       Sur?
Medications          Med-      Med=       Med?
Allergies                All-       All=         All?
Family History       Fam-      Fam=      Fam?
Tobacco              Tob-       Tob=       Tob?
Alcohol                 Alc-       Alc=        Alc?
Interventions         Int-      Int=        Int?
Social History        Soc-      Soc=       Soc?
ROS                    ROS-      ROS=      ROS?

For each of the fields in the encounter note and summary, there are starters available now. To obtain these, type the first 3 letters in the name of the field and then add either a dash “-“ or a “=” to the 3 letters. The ST item that has a shortcut comprised of the first 3 letters in the field name + a dash will usually offer a reasonable starting place for practicing data entry in the field. For example, in the Subjective, type “Sub-“ then Shift+F11 and select/download the ST item that has a shortcut of “Sub-“ … Subsequently, it will be in your local database and the space bar should activate the item (i.e. don’t have to download using Shift+F11 again). Adding an equal sign to the first 3 letters in a field name will often bring up a reasonable, starting pick list to use in that field. Purposely, the dash and equal sign both start with pick lists in many sections as that is often a reasonable starting point for learning. Adding a question mark to the first 3 letters in the field name will sometimes present a help message.

Starter Docuplates:
To use some simple docuplates, go to the Docuplate Library and search on “emc” to find the newest docuplates. Download one or more of the docuplates found by searching on “emc” . Open a SW chart and create a new, empty encounter. Select one of the simpler docuplates that has “(Compressed)” in the description, such as
     - Pharyngitis or Sore Throat (Compressed)
     - Gastroenteritis (Compressed)
     - Influenza (Compressed)
Click on the Insert button to put the docuplate into the encounter note. You should be able to just use it by clicking on items to edit them. In 5.1.8, you should also be able to also add typed text in most place much easier than in previous versions. Once you can click around and navigate within the simpler, “compressed” docuplates, then try some of the more robust examples that are labeled as “NG” for New Generation.
     - Pharyngitis or Sore Throat (NG)
     - Gastroenteritis (NG)
     - Influenza (NG)
These first examples of new generation docuplates are still evolving rapidly. For the near future, we are adding the date created to the docuplate descriptions. It will be wise to frequently check the docuplate library and replace older ones with newer ones. Over time, older docuplates may also cause the pick lists to display items that are less complete than newer ones. Probably the first thing to do is to insert one of the NG docuplates and immediately perform a “Remove Unused” (i.e. Control Key + F9). Doing this should give some insight as to how what might look complex, initially, is fairly straight-forward in the end. Play around by double- on various items in the encounter, then perform a “Remove Unused” when finished playing around.We will soon have a more complete library of starter docuplates. Most users will likely prefer to start with the docuplates in the library and simply edit them as desired, gradually, over time. Subsequently, more technical Instructions as to how to customize these new generation docuplates is in the works. It is going to be much easier to learn how to customize them if their work flow is familiar beforehand.

Path (Intermediate)- Custom Printing