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Script: Introduction to Charting Part 2 – Using Our Quick Charting Tools – Chart Parts, Template Forms, and Quick Add

In the first Encounter Note video, we described basic charting features. Now let’s talk about how you can really speed this process up. With almost no training or memorization, you can control the entire encounter note via the main text block using our intuitive quick charting tools. There are essentially three interrelated tools available in the MD HQ EMR:

  1. First, we have "Chart Parts", which is a fully customizable, quick-access templating system that you can use to insert text and/or suggested actions to a note, or even to complete every single part of the note.
  2. Then we have popup template forms for certain common encounter types. These are forms that you fill out during an encounter and then when you’re finished, the form values are used to populate the body of the note and sometimes other parts of the patient’s chart. These are probably a lot like the type of templates you might already be familiar with.
  3. The third tool is what we call a "Quick-Add" system that allows you to easily search for and add any action or facility to a note simply by typing search terms into the main text block and selecting from the suggested matches that appear.

Let’s take a closer look at these tools one at a time.

Chart Parts

Chart Parts is an incredibly flexible, completely customizable tool that allows you to do everything from inserting snippets of autotext that you often use, to adding an outline for your subjective and objective notes for a particular type of encounter, to automatically pulling in a combination of associated diagnoses, lab orders, prescriptions, charges, etc.

Add New Chart Part

To see how Chart Parts work, let’s create one from scratch. To do that, we go to the Admin menu and select "Manage" and then "Chart Parts." Click "add new" and give your custom Chart Part a name, the only rule being that it can’t have any spaces. And give it one or more nicknames which are keywords that might help you find the Chart Part when you search. Spaces designate separate keywords, so you probably want to avoid using too-common words like "patient" in here so that you aren’t swamped with suggested Chart Parts as you type your note. Including several variations of text you might search for will help you easily find your Chart Part in the future.

Type or cut and paste any text you want to appear in the main text block. Here, we’re going to include a basic workup for when a patient comes in with symptoms of a urinary tract infection. You want the text to be general, so that it can be used whenever a patient comes in with these symptoms. And, if you like, you can write more text than you will need and plan to delete parts that are extra or irrelevant in the particular case when you use the Chart Part. For example, we’ll include information about three common prescriptions for a UTI, planning to delete two of these that are not used in the particular instance. Another approach might be to have three different Chart Parts for UTI that have different prescriptions attached, and then to choose which Chart Part to use based on which drug is prescribed.

The text can also include variables, that is, placeholders that, instead of appearing exactly how they are typed, will insert context-specific information when the Chart Part is used, like the date, patient name, or patient’s medication list. Variable names are enclosed in double brackets. So, if I want to have the Chart Part automatically enter the patient's primary pharmacy, I type in pt_pharmacy surrounded by double brackets.

In addition to text, you can also add any combination of suggested diagnoses, prescriptions, orders, vaccines, alternative plan items (if they’re available) and charges or payments.

When the Chart Part is used, any actions that you’ve added become Suggested Actions in the note and can be accepted or dismissed one by one. Here, we'll add our diagnoses for UTI, our three potential prescriptions, lab orders, follow up and prevention information for the patient, and a charge for a short office visit. Remember that any of these you don’t actually need can easily be dismissed later.

Ok all set. If you want your Chart Part to be available to other people in the practice, click the "everyone" radio button at the top. Then just click "add new" and you’re done.

Using Chart Parts

OK now to use the Chart Part. Just type its name or nickname into the main text block, and suggested matches will appear to the left. If you just happen to be typing the name of a Chart Part but don’t want to add it to the note, keep typing and the suggestions list will disappear. Select a Chart Part using the mouse cursor or the arrow keys on your keyboard. Pressing the up arrow selects the topmost suggestion, while down, right, and left toggle over to the suggestions list where you can move up and down and then press enter to insert a suggested Chart Part.

Notice that the text from the Chart Part is inserted directly into the main text block, and our variable – the patient’s primary pharmacy – is printed here. Each action that we added appears as a suggestion that you can add to the note by clicking on it. Or, click on the x icon beside a suggestion to dismiss it. Suggestions that duplicate actions that are already in the note won’t be shown. Some suggested items, like prescriptions and vaccines need to be manually confirmed before they’re added so that you can add dosing or administration details. Add one or as many Chart Parts to the note as you want. Here, let’s insert a short Chart Part that we created to quickly insert text about whether or not the patient has had UTI symptoms before – compared to the more comprehensive Chart Part that we created, this one functions more like a custom autotext, helping you use your preferred shorthand to speed charting.

Template Forms

We also have some traditional template forms for common encounter types, which are accessed in the same way as Chart Parts, that is, by typing the name or nickname in the main text block and selecting the one you want from the list provided. Selecting a template will pop up a fillable template form for the particular encounter type, which you can fill out using the buttons and fields provided. In this case, as you mark results as normal, you can see that notes are automatically added. You can change the default notes for a normal or abnormal result by editing the text and then checking this box to the right to set as default.

This template also adds readings for Tethys blood pressure, weight, and height to the vitals block and, if you add an allergy, it adds a new entry to the allergy, intolerance, discontinued medication block. When you’re finished, the form is used to generate detailed text for the encounter note. And notice our new readings in the vitals and allergy blocks over here.

Quick Add

Our third quick charting tool is something that we call "Quick Add", and it makes it so that you can add any action or facility from the database with just a few keystrokes. All you have to remember is a set of intuitive, two-letter prefixes that tell the system where to search in the database with the search terms that you provide.

Here’s how it works. You type in the two letter prefix that designates the type of action or facility you’d like to add:

dx for diagnosis

ph for pharmacy

rx for drug/prescription

sp for specialist

or for order

xr for radiologist

vc for vaccine

lb for laboratory

al for alternative action item

ch for charge

And following the two letter prefix with no space, you type in search terms for the action or facility you’re looking for, with multiple search terms separated by underscores. Let's go ahead and add some labs for Tethys by typing in lb_cbc for complete blood count, and lb_chem for chem 8. And, let’s add a referral to a dermatologist in Fairfax by typing sp for specialist and derm underscore Fairfax. As you can see, these orders and the referral information now appear in the text of the note and there are corresponding suggested actions to the right to order a complete cbc and metabolic panel and to assign this doctor as one of Tethys' preferred specialists. As before, just accept by clicking on a suggested action, or click on the red x to reject it.

As you can see, this is a great tool if you prefer to speed things along by using your keyboard rather than going back and forth between your keyboard and mouse.
So, to summarize: chart parts are fully customizable, text-based templates that can add text and/or actions to the note. Templates are guided forms that insert text into the note. And Quick Add lets you search for and add any action or facility in the database by using one of the intuitive, two-letter prefixes.

We've designed these quick-charting tools to be easy to access and use – without requiring almost any memorization – and to do more of the work for you. And while it might seem daunting after this whirlwind overview, we think you will be surprised at how quickly you get the hang of it. And remember, if you feel more comfortable, you can always chart perfectly easily without using any advanced charting tools.

For more information and videos and our online help, go to www.md-hq.com.