Writing And Maintaining Clinical Notes

You can enter documentation in NoteWriter at any time during a patient encounter; for example:

• During pre-rounding, when you review critical lab results
• During room visits, when you meet with patients or observe their condition
• After a patient encounter, when you assess a patient’s progress and determine a plan of action

In addition, NoteWriter can be integrated with the following applications:

• Commure Pro Desktop Charge Capture: This integration allows you to complete all of your billing tasks as part of the documentation workflow, ensures that billing is done in a timely manner, and also reduces the likelihood of billing errors.
• Commure Pro CPOE: This integration allows you to enter new orders as part of the documentation workflow and ensures that orders are placed in a timely fashion.

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Setting Up Your NoteWriter User Preferences

All users can view and edit only those user settings specified on the Preferences tab, depending upon the access level of each user. Level 3 user preferences include the following:

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Note Pickers

You can configure supplemental Note Pickers at the individual user level, which are added to the user’s list of department-level Note Pickers. Note Pickers define the list that each department provides to its users to enable them to select a note template. Select [Edit] to display the Note Pickers window. Selecting an item displays the Edit window for the selection. For more information, see Configuring How Visits are Selected During Note Creation. Allow Data Selection on the Portal/Handheld This setting determines whether the user has permission to copy data from other Commure Pro modules into a note. When this setting is enabled, the user can access one or more of these modules from within the NoteWriter interface. The modules that can be accessed from the NoteWriter interface are determined by template configuration, but can include any of the following:

• Allergies
• Clinical Notes
• CPOE Orders (web application only)
• Lab Results
• Medications
• Orders
• Test Results
• Vital Signs

Granting access to the user enables them to copy data from any of these modules into a note, provided the note template references these modules. Clinical Data Insertion Timeframe This setting specifies the duration (hours) that pre-selected clinical data remains available to add to a note. You can configure this setting so that all pre-selected data expires after a specified time limit. Setting an expiration time ensures that clinical data remains relevant when providers pre-select this data from one or more modules in the Physician Portal to include in a note at a later time. You can configure this setting to specify any number between 1 and 72 hours. The default setting is 24 hours. A setting of 24 enables providers to pre-select clinical data up to one full day before adding it to a note. Once this limit is reached, the data is no longer available to insert into a note.

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Navigating to the NoteWriter Interface

The NoteWriter application displays within the Commure Pro Physician Portal. The NoteWriter interface typically displays on the Patient List tab, on the right-hand side of the screen. Because the application is template-driven, there is no universal note interface shared by all institutions and departments. However, it is expected that many note templates will share several properties and characteristics. You can access the NoteWriter application using the Add icon next to the Clinical Notes link or the Actions drop-down from the following screens in the Commure Pro Physician Portal:

• The Patient List tab, where the drop-down displays at the top right of the screen when you select a patient from the list
• The Patient Search screen, where the drop-down displays at the top right of the search results screen
• The Sign-Out Summary tab, where the drop-down displays at the bottom right of the screen

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Navigating Within the NoteWriter Interface

The NoteWriter interface is designed to be flexible, supporting many workflows. You can easily navigate between the sections of your note in any order; you are not required to complete one section of your note before moving to other sections in sequence. Typically, note templates include Next and Previous buttons to facilitate an orderly, sequential navigation between all of the sections in the template. In addition, note templates frequently include tabs enabling you to jump to any section of your note in a single click. For example, a progress note template enables you to navigate between any of the four parts of a SOAP note at will, and also provides a way for you to navigate to the Desktop Charge Capture module to enter charges into your note at any time. No matter what sequence you follow as you enter data into your note, signed notes are formatted in a uniform manner so that you can easily and predictably locate all of your information in your finalized notes once you sign and print them.

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Navigating Between NoteWriter and Other Modules

NoteWriter is designed to be flexible, so that providers can create and maintain notes in a variety of situations and clinical settings. This flexibility enables providers to easily navigate between their note and other areas of the Physician Portal with a minimum of clicking. Providers can also record notes in the face of frequent interruptions, since the NoteWriter interface enables them to create and maintain many types of notes, store these notes in draft form, and sign them at a convenient time. To facilitate the easy exchange of information between modules, NoteWriter is designed so that users can navigate away from an open note to go to other Commure Pro modules without losing their place. When users return to a note in progress from another Commure Pro module, their note remains as they left it. In addition, notes can include links to other modules so that users can easily add data from other Commure Pro modules to the body of a note. For example, users of anyCommure Pro default progress note template can select a variety of clinical data from the patient record without having to navigate away from the note interface.

• When loading the Orders tab- Loading CPOE Module
• When loading the Charges tab- Loading Charge Module

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NoteWriter Display Properties

There are a few unique features of the NoteWriter interface that differentiate it from the other Physician Portal modules in its display properties:

• When accessed from the Patient List tab, the NoteWriter note template screen expands to occupy more space within the Physician Portal interface.
• The note template header can provide links to other Commure Pro modules, enabling you to navigate easily between these modules when you create and edit your notes.
• The note template header provides links to all sections of a note, enabling you to navigate freely between these sections as you enter your note data.
• The NoteWriter interface enables providers to navigate to other modules without losing their place. When they return to a note in progress from another Commure Pro module, the note remains as they left it on the Patient List screen.
• The Pop Out/Pop In feature allows a user with two monitors to display the note in a side-by-side view, and adjust the display windows.

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Working with Note Templates

Note templates provide the framework for adding your clinical documentation. The NoteWriter application provides note templates that can be used or customized for departments or other groups to accommodate a particular work flow or clinical situation that is shared among a group of providers. Templates can also be customized for individual use, so that providers with a specialized focus can choose a template with the correct level of detail for a particular clinical setting. The NoteWriter application provides the following basic templates that you can work with to enter all of your clinical documentation:

• History and Physical Note
• Progress Note
• Chart Notation
• Operative Note
• Consult Note
• Attending Addendum

If your administrator has enabled a single template for your department, your note displays on the right-hand side of the Patient List window and you can begin to enter data into the note. If your administrator has enabled multiple templates for your department, you are prompted to select your template from a list of available templates. Once you choose the patient visit corresponding to your note, select a template and then your note displays on the right-hand side of the Patient List window. You can begin to enter data into the note. To customize an existing template or create a new template, consult with your Commure Pro representative.

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Understanding the NoteWriter Workflow

This section describes the basic workflow for creating and maintaining notes using the NoteWriter application. A SOAP progress note is the note template type provided as an example throughout this workflow. Typically, the basic NoteWriter workflow includes the following tasks. (Note that the first of these tasks is only relevant to pre-rounding workflows.)

1. Select clinical data prior to starting a note: (Pre-rounding scenario only). This task involves steps for selecting the clinical data from one or more clinical data modules within the Physician Portal that you want available in your note when you start it. See Linking Clinical Data to Start a Note.
2. Start a Note: This task involves how to access NoteWriter, select a note template, and specify a date and time for the note. See Starting a Note.
3. Enter data in the note: This task involves steps for choosing one or more data entry method(s) and adding or removing clinical data to/from a note. See Entering Data Into a Note.
4. Save a Draft Note (Optional): This task involves steps on how you save a draft note. Detailed information is also provided about how the Auto Save feature works. See Saving Draft Notes.
5. Work with Draft Notes (Optional): This task involves steps for previewing and printing your draft note(s). See Working with Draft Notes.
6. Modify a Note (Optional): This task involves steps for editing, canceling, or deleting a note. See Modifying New or Draft Notes.
7. Sign a Note: This task involves all the steps used to sign, submit, and print a finalized note. See Signing Notes.

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Starting a Note

Each time that you start a note, you are prompted to select from a list of note templates, provided you have access to multiple template types. If your administrator has created a single note template for your department, this template opens without prompting you to select a template type. Only note types that are relevant to the visit type for which you are writing a note are available. (See Note Pickers) Before selecting a template, you must first select a patient visit (unless an administrator has configured your system for auto-selection of the currently-selected visit). The templates displayed on your list may change as you select different patient visits, since templates are specific to visit type. Once you select your visit, all of the templates associated with that visit type are displayed in a searchable hierarchy, and you can select the template you want. For more information about configuring auto-selection of visits, see Configuring How Visits are Selected During Note Creation.

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Starting a Note from the Patient List

To start a note from the Patient List:

1. Select a patient visit from the Patient List.
2. Click the Add icon located next to the Clinical Notes link in the center column of the Patient Data display area and one of the following displays:
   • If you only have one note template enabled, your note displays on the right-hand side of the Patient List window and you can begin to enter data into the note.
   • If you have multiple note templates enabled, the Select Note Template screen displays. All templates available for the visit type you select are displayed. Continue to the next step.
3. Select the template you want from the list.
   If there is a long list of templates, you can narrow the selection of note names by using a filter to search by specifying all or part of a template name. You will be filtering through notes that have been assigned specifically to you or through the relationship to your department/groups. If the same note type exists in more than one department to which you belong, only one instance of that displays in the filter results. Begin entry into the Search bar (displayed with a magnifying glass icon) to filter on any word in the note name, and select from the results when the name appears. If you do not want the default visit, select another visit from the drop-down list that corresponds to the note you want to create.
   The note displays on the right-hand side of the Patient List window and you can begin to enter data into it.
4. Specify a note creation date and time if you want to specify settings other than the current date and time. Please be aware that you cannot assign a future date to your note.
   It is likely that you will want to use the current date and time (default settings) when creating most of your notes. However, you may want to create notes for one or more visits that occurred in the past. In such cases, you can edit these fields to specify any date and time value that occurs within the selected visit date or range of dates.
   If the current date falls outside of the date range for the selected visit, the note creation date field is assigned the following default values:

   If the visit type is:	The note date defaults to:
   An outpatient visit	The scheduled date
   An inpatient or ER visit	The discharge date

   When the current date is outside of the selected visit date(s), the note time field is not populated with a default value.

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Starting a New Note for a Patient who Has Draft Notes in Progress

If you attempt to start a new note for a patient that already has one or more draft notes in progress, the note does not initially open nor are you initially prompted to select a note template. Instead, you are prompted to review existing notes for the selected patient that remain in draft status. You can click on any column in this list to sort your list of draft notes by date, template name, or by visit description. If you still want to start a new note after reviewing the Notes in Draft Status list, click the Create New button and your note template opens. If you have access to multiple templates, you are instead prompted to select a visit date and an associated template. Note that the list of available visits includes the visit dates for your draft notes in progress, so you must make sure to select a different visit date, unless you want to start a new version of an existing note from scratch.

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Customizing your Note Templates List

The list of note types available to you when you enter NoteWriter may include some notes that you use more frequently than others. In this case you can customize your notes list to change the sort order so your most frequently used templates appear at the top, and even hide note templates you don’t want to see. To customize your note templates list:

1. In the New Note section, click Customize. The Note Type List Customization options display.
2. Customize your notes list using the following options:
   • Click the Show/Hide icon to include a note as Visible or exclude it as Hidden .
   • Hover over a note template that you want to move so the Sort handle displays and then drag-and-drop it to a new position in the list.
3. Click Save to save your changes. Clicking Cancel or Close will discard any changes and close the Customization options.

Show Settings that control this feature

Admin - User - NoteWriter - Note Pickers - Hiding Departmental Items or Categories in a User’s Note Picker

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Assigning a Specialty to Your Note

If your administrator has configured your system enabling you to designate a specialty for your note, you can select from any of the specialties that are available to you. The Specialty drop-down menu provides a list of the specialties that are configured for your specific area(s) of expertise. Depending on how your administrator has configured your system, you might need to select a specialty before you can sign and submit your note. If your administrator configures your account with a default specialty, this default specialty is used by default each time that you create a note, but you can change this to any of your other associated specialties.Assigning specialties to your notes can help you to locate a specific note, especially after you enter several notes and your list of notes starts to grow significantly on the Clinical Notes pane. The specialty that you select during note entry displays under the associated note type in your list of clinical notes. If the list of specialties available to you is incomplete or needs to be updated in any way, contact your administrator. Once you select a visit and (optionally) a specialty, you can also specify a date and time for your note, although you will probably use the default settings (current date and time) most frequently, such as for active inpatient or outpatient visits, or on the discharge date. Upon printing (or previewing) the note, the specialty that you have selected displays in the note header, below the information used to identify the note type.

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Reclassifying a Note

To set the note types to which a note may be reclassified:

1. Select a template name from the Note Template Maintenance window.
2. From the Add/Edit Note Template window, select Edit in the field Allow to reclassify note to types.
3. Select a note type to reclassify the note and click OK.
   When the note reclassification has been enabled for a template, select the note types to reclassify before signing the note. If not, the Note Type field on the note picker page does not display until the note type is reclassified.

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Selecting a Visit

In order to open a note template for editing, a patient visit must first be selected for the note. Some providers are configured in their user profile to auto-select a visit when starting a new note. If a visit is not auto-selected, then a visit must be selected from the Visit drop-down. Because providers are writing notes for different purposes on visits and each visit needs a “standard” note type (H&P, Progress Note, Discharge Summary), there is an option to check visit times to avoid conflict with visits that are close together. The current visit on the patient list may not be the one that the physician wants to document. Preferences allow for a passive or active alert to the provider for a check on visits in proximity. Administrators can configure auto-select for visits at the and User level and can configure nearby visits at both the Institution and User levels. To select a patient visit for a note:

1. Click the Visit drop-down near the top of the screen.
2. Select the visit you want for the note and then click Close.

Show Settings that control this feature

• Admin - User - Patient List - Auto-select visit during “Add” Activities
• Admin - Institution - NoteWriter - Check number of days for nearby visits
• Admin - User - NoteWriter - Close Visit Alert Type

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Managing Notes that are in Progress

After you open a note template and begin entering data into a note, you can choose from the following actions:

• Print Preview: Displays the note using the print format. You can use Print Preview to inspect a note before signing it, to ensure that it is complete.

For more information, see Previewing and Printing Draft Notes.

• Save as Draft: Saves the note in draft form. Once in draft form, a note can be re-opened and completed at a later time, but only by its author. For more information, see Working with Draft Notes.
• Sign/Submit: Finalizes the note. Once a note is finalized, it displays on the Clinical Notes page and you can no longer make edits to it. For more information, see Signing Notes.
• Cancel: Closes the current note without saving it in its current form. When you cancel out of a note you are prompted to confirm that you want to exit the note, after which the NoteWriter application closes and the Physician Portal reverts to the module that displayed for the specified patient before you started the note. For more information, see Canceling Draft Notes.

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Entering Data Into a Note

In NoteWriter, there can be many ways to enter data into a note. The methods of data entry available to you depend on the type of template that you are using and the type of data being entered. In the sections and chapters that follow, detailed information is provided about each of these data entry methods. The Progress Note note template provided by Commure Pro using SOAP includes examples of each of these methods. Please note that data entry methods can include any combination of the following: As you enter data into your note, the note is saved automatically at intervals determined by your administrator. However, it is recommended that you manually save your notes frequently to avoid having to rely on the auto-save feature which, depending on configuration, may not reflect your most recent changes. The following sections describe the different data entry methods that you can use to add clinical information to your notes. Many of the methods outlined in these sections are especially relevant (but not exclusive) to the SOAP progress note.

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Customizing Note Entry

You can customize the display of ROS and Exam entries for a note type in the Note Entry window, by choosing whether to hide entries not desired in the display. This is done using the Settings gear icon displayed in the upper-right of the Note Entry window. Selecting this icon displays the Note Entry Settings window for that type of note. In this window, you can select from the lists of ROS and Exam entries, with the option to hide them in the Note Entry window and for Insert Previous. A scrollbar allows you to see the full list of fields for the tab on the template. Make selections and select Save to save your selections, or Cancel. For Insert Previous, there are the following conditions:

• Any system may be hidden from Note Entry, but a system cannot be hidden from Note Entry and visible in Insert Previous.
• A system may be hidden from Insert Previous and visible in Note Entry (this assumes the physician never wants to default in information from previous notes).
• At least one system must be present in ROS and Exam – all systems may not be hidden.

Show Settings that control this feature

Admin - User - Personal Preferences - NoteWriter - Note Entry Settings

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Performing Spelling and Grammar Checking on Note Content

As an alternate option to using browser spellcheck, a third party spelling and grammar checking program is embedded within the text fields belonging to each note template to detect any misspelled words, including medical terminology. Spell checking functionality is embedded within the various types of text fields that clinicians use to enter free-text data into their notes, including the Patient Narrative field, Quick Text fields, Insert Previous fields, and fields used for entry of ROS and Exam data. In a text field, click the Proofreader icon in the upper-right of the field to display the Proofreader dialog box. The highlighted word shows as the current selection below, and selectable suggestions are listed as alternate spellings. Buttons below allow you to change to the suggested spelling you have selected, ignore the suggestion, or close the dialog. If there are more misspellings, the tool will highlight them individually in order as they appear.

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Entering Data as Free Text

Free text fields enable you to type data directly into the NoteWriter interface. Once a note is signed, printed, or previewed, free text data displays as paragraph blocks in a note. You can use free text fields to enter descriptive data about a patient whenever the other data entry options are inadequate for providing the level of detail you want. Templates can employ free text fields in many ways. They can appear in any section of a template, and they can serve a variety of purposes. In some cases, free text fields are simple and direct; in these cases, you are required to enter descriptive data from the keyboard. The text box for a Patient narrative is one example of a simple free text field. Free text fields can also be provided as part of other data entry methods. For example, free text fields can be used in conjunction with a body systems checklist to enable you to add and edit existing information until you get the desired level of specificity you want. In such cases, the true power of NoteWriter is revealed, as these hybrid methods provide the convenience of automation without forcing you to sacrifice any of the freedoms available to you in ordinary free text entry. Notes about free text fields:

• Even though these fields are “simple”, you can typically use Quick Text in conjunction with many types of free text fields to automate the redundant aspects of text entry without sacrificing the freedom that it provides.
• You may copy and paste text from another document into a text field, but you may see random characters inserted for hidden formatting which can cause issues with the note. NoteWriter’s free text fields use a plain text editor which cannot translate hidden format characters. For example, documents using the PDF format will have hidden formatting characters. To prevent this issue, copy and past your text from another document into a plain text editor (such as Notepad) to remove hidden characters, and then copy and paste the text from the plain text editor to your note’s free text field.
• Templates may also include free text fields to gather data, such as statistics and other metrics from examinations. For example, free text fields might be provided for you to enter vital signs, such as in the Exam section of the default SOAP note template. When it is available from its corresponding clinical data module, this data is automatically populated in the correct fields. You can edit the data in any of these fields, but note that any changes made to this data are saved with the note instance only; these changes are not propagated back to the clinical data module. Example of Autopopulated Data: When a diagnosis code is chosen for a charge transaction in the Charge Capture application, the diagnosis code is automatically populated in the appropriate Note section. Both Charge Capture and NoteWriter applications are required.

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Inserting Quick Text

Quick Text enables providers to simplify the entry of frequently-used phrases, terms, and longer standardized text such as a typical surgical procedure. Use of Quick Text entries can save time by eliminating redundancy that can occur when you enter notes for commonly-encountered clinical situations. If your department administrator has defined a set of Quick Text entries for your use, then you can begin using this feature at any time. Otherwise, you must first define Quick Text for your own use. For more information, see Managing Quick Text Entry. You can insert Quick Text from any template field that displays the Quick Text icon . For the list of available entries, click this icon and the list of entries is displayed. If this list has been organized into a hierarchy of categories, you might see category headings instead of or in addition to regular Quick Text entries. Categories display in bold text, and are identified by an icon + that you click on to reveal Quick Text entries or additional categories. To Insert Quick Text into a Text Field:

1. Make sure that the cursor is positioned where you want the Quick Text entry to be inserted into the text field. Frequently you enter Quick Text as you enter text into a field, so positioning of the cursor will be unnecessary.
2. Click the Quick Text icon that displays to the right of the text field. The Insert Quick Text dialog box displays your list of Quick Text entries.
3. Select the entry or entries that you want to enter from the dialog box. If these entries are categorized, you might need to click on one or more categories and sub-categories to locate the entry you want. The Quick Text entry is added into the text field.

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Using Shortcuts to Insert Quick Text

If you have shortcuts defined for your Quick Text entries, you can use them to quickly insert your Quick Text entries as follows:

1. Make sure that the cursor is positioned where you want the Quick Text entry to be inserted into the text field. Frequently you enter Quick Text as you enter text into a field, so positioning of the cursor will be unnecessary.
2. Enter the shortcut for your Quick Text, and then press Enter. The Quick Text entry displays in the text field.

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Carrying Forward Data Using Insert Previous

As with Quick text entries, the Insert Previous feature helps to eliminate redundancy in data entry. This feature enables providers to carry forward data from an earlier note and revise this data as needed to document subsequent visits for a particular patient. As a result, you can restrict entry of new data so that you only need to document the incremental changes in a patient’s status without needing to re-enter this data from scratch on subsequent visits. When you use the Insert Previous feature to access previous notes for a particular patient, you can restrict your search scope to include only your own notes. When you access previous notes in this way, you are given access to all of your recent notes, regardless of whether they exist in draft form or as completed notes. You can also widen the scope of your note access to include all notes belonging to your department. In this case, you are given access to all completed notes that have been signed by providers in your department in addition to your own signed and draft notes. Whether you choose to restrict your search scope to include only your own notes or all notes belonging to your department, your selection will be retained across login sessions so that you can configure this setting once and your configuration will remain until you decide to change it. The number of previous notes that you can access to copy forward data is configured by your administrator. To establish which notes qualify as recent, all notes are sorted by the date and time that you assign to the note, not by the date that you create the note. These notes are sorted so that the most recent note date is displayed first in the series of past notes that are made available to carry forward data. Also note that, since all notes signed by members of your department are included in the list, you see fewer of your own (draft and signed) notes. You can use the Insert Previous option to carry forward any data in your template that supports this feature. The types of data entries you can access depends on how your administrator configures the NoteWriter application. In the default progress note templates included with NoteWriter, the following types of data support the Insert Previous feature to carry forward data:

• Patient narrative: The Insert Previous feature can help to save time when a patient’s status remains largely unchanged over the course of several visits. Instead of re-typing the patient narrative on subsequent visits, such as over a series of consecutive days, you can copy forward the entire narrative, and then make any minor revisions as needed.
• Body systems: When used with a body systems checklist, the Insert Previous feature enables you to copy forward one or more entries from a previous checklist entry. The number of previous checklist entries you can access depends on your configuration. As you click through the previous notes, you can select from any of the body systems entries (specifying either normal or abnormal results for each) that were entered in each previous note instance. For each previous note, the list of available entries includes only those body systems for which results were entered. When you select a body systems entry to copy forward, the entire entry is copied into its appropriate field in the current body systems checklist, including any Quick Text entries used in the data field. If your template supports multiple checklists, unique identifiers are used to ensure that all body systems data is copied into the correct checklist that corresponds to the previous note’s checklist. After you insert a previous entry, you can edit this entry as needed to suit the current circumstances.
  The display of body system lists is customizable.
• Problem list entries: As with the body systems checklist, the Insert Previous feature enables you to copy forward one or more entries from a previous note’s problem list. As you click through previous notes, you can select from problem descriptions that were entered in each previous note instance. The number of previous problem list entries you can access depends on your configuration. When you select problems to copy forward, the problem descriptions are copied onto your current note’s problem list. After you insert one or more previous entries from a problem list, you can edit these entries as needed to further refine these problem descriptions.

Show examples of carrying forward your own notes and from your department

Example #1: Carrying Forward Data from Your Own Notes OnlyYour administrator configures the Insert Previous feature in your institution to include the eight most-recent notes. After clicking the Insert Previous link to carry forward data into a particular field, you (Dr. Alfred Moon) decide to search in your own past notes only, and so you select the My Notes radio button. The available past notes includes your eight most recent notes (by note date), in either draft or signed status. These notes are sorted so that the most recent note date is displayed first in the series of past notes that are made available to carry forward data. To view another available note, click the Previous and Next arrows in the upper right corner of the window.Example #2: Carrying Forward Data from Your Department’s NotesAs with the previous example, your administrator configures the Insert Previous feature to include the eight most-recent notes. This time, however, you (Dr. Alfred Moon) decide to search through all past notes in your department, and so you select the My Department’s Notes radio button. The past notes available includes the eight most recent notes (by note date) meeting the following criteria:-Any of your own past notes, in either draft or signed status-Any signed notes authored by colleagues in your department

To carry forward data using Insert Previous:

1. Click on the Insert Previous link that displays above any data field in your template that supports this feature. Note that this link is active when you (or colleagues in your department) have already created one or more notes in the past. For example, you might decide to carry forward patient narrative from a past visit. The Data to Insert from Previous Notes window displays.
2. Use the radio buttons in the upper left to choose either:
   • My Notes: To display your own most recent draft or signed notes.
   • My Department’s Notes: To display your most recent draft or signed notes, along with recent signed notes that were authored by colleagues in your department.
   Your configuration remains unchanged across note instances, so once you configure this setting, your preference remains intact until you decide to change it.
   After you make your selection, the Data to Insert from Previous Notes window displays the most recent entries meeting your specified criteria.
3. Navigate through previous note entries for this field by clicking the Previous and Next icons. When you find the correct entry, select the checkbox next to the data you wish to carry forward if it is not already selected.
   As you view a note entry, all the data for that entry is automatically selected. To clear a selection, click the checkbox of the selected entry. To clear all selections, click the Clear All button.
4. After you select the data of the entry that you want to carry forward, click the Insert Selection button. The selected data of the previous entry is inserted into the current field. If necessary, you can modify text from this entry to suit the current note.

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Using Auto-Pull to Enter Data

A new method of automatically pulling additional field types that contain historical information now speeds the note writing process. The Auto-pull option is available from the NoteWriter Template Editor, on the Standard page for text, text box, and inline field types, with a default of disabled. When a note template field has been configured to auto-pull data, the provider creating a note sees that the information is already populated into the note as text information (for text/text box fields), and as normally populated fields for inline fields. The data looks the same as if the provider had used Insert Previous and manually included the data. When a template is configured for Copy Previous Note, enable the Allow Copying option on the Standard NWTE page to allow a field to be copied from a previous note. Then enable Auto-pull to bring in the most recent value entered in previously signed notes. The fields to insert data into must have the same field ID as the field from which the data is pulled, regardless of note type. A menu of note types is displayed, and is where you select to specify only the types of notes to pull data into and the order in which those notes are considered. If all note types are disabled, values are pulled from the most recent note, without favoring any specific note type. Click on the center of each item to include or exclude that note type, and click the Left and Right arrows on an item to move that item into higher and lower importance, respectively. Then select to restrict the notes from which values can be pulled:

• No Restrictions: Notes from all departments are considered.
• Within Departments Only: Only notes within a provider’s affiliated departments are considered.
• Using Department IP Templates: In addition to the Within Departments Only restriction, notes from templates specified using the Include Department Notes In Insert Previous are considered. For more information, see Include Department Notes in Insert Previous.

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Entering Data into Body System Checklists

If your template supports it, you can enter all data from your patient history and physical into body systems checklists. This method of entering data can improve your efficiency, since it enables you to enter pre-defined descriptions for all standard (normal) results from the history and physical. As a result, you can often enter data for a body system with a single mouse click, and focus on the noteworthy areas of the history and physical, which are the abnormal results. The body systems checklist may be included in different areas of a template; the type of data that you enter into it may relate to a particular phase in your workflow, as represented by where the checklist appears in your template. When you sign and print a note, only the body systems that you select from a checklist are included in your signed and printed note. To make the formatting of all signed and printed notes consistent, these systems are organized in a particular, uniform order. No matter what order you use to enter this data, it is organized in all printed notes (including print preview mode) in a standardized way.

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Entering Review of Systems Data

A body systems checklist can be used for data from a review of systems (ROS). For example, if your template includes a body systems checklist as part of the subjective phase of a SOAP progress note, you enter the data from your subjective assessment of each patient into this checklist. For example, when a provider selects Normal for a body system (such as General or ENT), standard text describing normal results are filled in automatically, including any Quick Text entries that were entered in this field. But when a provider clicks Abnormal for a body system (such as CV for cardiovascular), a blank text box displays so that the provider can enter specific data for the cardiovascular (CV) component, since pre-defined terms cannot be used for abnormal results. Pre-defined text corresponding to each body system is applicable to the subjective phase of the review only. For example, when you click Normal to enter data from a normal ENT/mouth exam, the pre-defined entry for the subjective ENT/mouth exam, “Negative for sore throat. No otalgia. No rhinorea.” is added to your note. Also note that you can modify the text for any body system as you complete your note, including the pre-defined text entries (defined in your template) that are added for normal body system results.

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Entering Exam Data

When used in a different section of a note template, the body systems checklist can be used for entering different types of data. In the example that follows, the checklist is included as part of the Exam tab. Rather than using the checklist for ROS data, you use this checklist to enter all of the data from a patient’s physical exam. For example, when a provider selects Normal results for the constitutional and ENT systems, and click on the Abnormal link to enter specific data for the cardiovascular (CV) component, since pre-defined terms cannot be used for abnormal results. Note that in this case, the pre-defined text corresponding to each body system differs from the text provided on the Subjective tab. In this case, these terms relate to body systems data that is entered during a physical exam. Vitals and I/Os data over a 24-hour period is automatically pulled into the Exam tab.

• Vitals from last 24-hours are auto-pulled based on the note start time.

  Show Ecample

  For example, a note started at 11:00 a.m. on September 3 will include Vitals from 11:00 a.m September 2 to 11:00 a.m September 3.

  • [ADD IMAGE]
• I/Os over a 24-hour period are auto-pulled starting with the Shift Start Time from the last completed shift range.

  Show Example

  For example, if the Shift Start Time is 7:00 a.m. and a note is started at 11:00 a.m. on September 3, I/Os are auto-pulled from 7:00 a.m. on September 2 to 7:00 a.m. on September 3.

  • [ADD IMAGE]

Note that you can delete vitals and I/O data from a note with a single click of the trash cans associated with each type of data. This can help to free up additional space for adding affirmations and/or other updates to the progress note. In addition to the above methods for entering data from a history and physical, you can carry forward data from a previous note so that you are not required to entire duplicate data over the course of days, weeks, or even months. You can also select from any terms and/or phrases that have been defined as quick text entries.

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Entering Results Into a Body Systems Checklist

To enter results into a body systems checklist, navigate to the template section that contains the checklist, and then:

1. For each body system that you identify as abnormal through either observation or testing, click the Abnormal link in the corresponding row. An empty text box displays to the right of the checklist. Enter all results into the text box, either as free text or through the use of Insert Previous. In addition, if Quick Text entries have been defined for one or more of these entries, you can add these entries by clicking the Quick Text icon that displays next to each body system result.
2. For each body system that you identify as normal through either observation or testing, click the Normal link in the corresponding row. Alternatively, you may be able to simplify the entry of all body systems results that you identify as normal, if your template supports this ability. To enter all normal results at one time, check your template for an option such as ALL and click the link that corresponds to Normal results. Each normal body systems entry displays to the right of the checklist. If there are pre-defined terms from your template used to describe a body systems result, they are included in the text box.
3. Review the entries for each result. You can add to or edit each these entries as needed to refine each description.

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Deleting Entries from a Body Systems Checklist

To delete an entry after you select it from the body systems checklist, navigate to the template section that contains the checklist, and then:

1. Locate the entry that you want to delete. All entries display to the right of the body systems checklist.
2. Click the Delete button that displays to the left of the specific body system entry that you want to delete. For example, if you want to delete the ENT/mouth body system entry, simply click the icon in its corresponding row. The body system entry is removed from your list, including any Quick Text entries used in the data field. You can select it again from the body systems checklist if you choose to enter a different result.

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Entering Clinical Data from the Physician Portal

Your note template may allow you to enter clinical data directly from the Physician Portal. You can do this by linking the data from the Physician Portal without losing your place in the note. If this is enabled, you will see links for any of the following modules:

• Allergies
• Clinical Notes
• CPOE Orders
• Medications (including home medications if available)
• Lab Results
• Orders
• Test Results
• Vital Signs

Once you link any of the above clinical data to a specific note, this data displays to the right of the clinical modules links, in abbreviated form. For example, linked test results identify the test name, along with the date and time of the test. By hovering over these abbreviated results, users can see the details pertaining to a particular test without having to exit the note by navigating out to a specific module. The Show Clinical Data button is now available through NoteWriter, such as in Patient Search and editing a note from the Inbox, except in pop-out mode, because there providers can add clinical data directly to notes through the CPOE lists.

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Linking Clinical Data While in a Note

The basic procedure for linking data from a module in the Physician Portal while in a note is as follows:

1. Navigate to the section of your note where these clinical data module links reside, and then select one of the clinical data module links within the note. For example, click the Allergies link. The Physician Portal Patient Data Display opens and displays the Allergies option display.
2. Select the checkbox of the clinical data that you want to add to your note. For example, select Penicillin as an allergy you wish to add.
3. Click the Copy to Note button in the lower left corner of the screen. You are returned to the section of your note where you chose to link the data. The name of the clinical module, such as Allergies, displays with the reference to the clinical data you selected, in our example, Penicillin.

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Linking Clinical Data to Start a Note

The basic procedure for linking data from a module in the Physician Portal before you start a note is as follows:

1. From the Patient List, select a patient, and then select the clinical data option in the center column that you want to link to a new note. For example, click the Allergies option in the center column. The Allergies option screen displays.
2. Select the checkbox of the clinical data that you want to add to your note. For example, select Penicillin as an allergy you wish to add.
3. Start a note (see Starting a Note).
4. Navigate to the section of the note where the clinical data module links reside and you will see the clinical module, such as Allergies, displayed with the reference to the clinical data you selected, in our example, Penicillin. For more information on how to more effectively link clinical data in your note, see Linking Clinical Data from Other Modules.

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Entering Data in Date Fields

Some note templates include a date field for specifying details such as a surgery date. Providers can type into the field to enter a date or click the Expand button to use a date picker to choose a date from a calendar pop-up. If the field has been configured to include time, providers can type the time or use the date picker to specify the values. When typing into a Date/Time field, use the same time format for which the system is configured (12-hr/24-hr). Tips for entering time using the date picker:

• Double-click in the Hours and Minutes fields to type values manually, or click the arrow buttons to change the time incrementally.
• In the Hours field, you can toggle between the lowest value (01) and the highest value (12) to quickly jump to either end of the clock by clicking in the field and then pressing the Backspace key.
• In the Minutes field, you can reset the value to 00 by clicking in the field and then pressing the Backspace key.

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Radio Buttons on Templates

Some types of data are best captured using radio buttons. For example, data requiring a specific follow-up activity might be identified using a radio button selection. Institutions or departments can provide this type of data entry method in a template to collect and identify data that lends itself to easy categorization.

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Entering Assessment and Plan Information

If your template supports it, you can enter all assessment and plan data from patient visits into your note templates. In the default SOAP note template that is provided for documenting patient progress notes, an Assessment/Plan section (A/P) is included that enables you to enter your patient assessment and plan data in the following ways: When the note is signed and submitted, any new diagnosis codes are automatically added to the patient’s problem list and are assigned a Type of “Acute” and a Status of “Active.” In addition, the current date is used for the Last Used date and the Onset date.

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Maintaining the Patient’s Problem List

If your template supports it, you can document all patient problems using a problem list. The default progress note templates that are included with NoteWriter provide such a list, so that you can enter all problems associated with each of your patient visits. As you search for and enter your diagnoses using the tabs on the left-hand side of the screen, the problems associated with these diagnoses are added to your problem list on the right-hand side of the screen. An empty text field is provided with each problem on this list so that you can enter a specific assessment that pertains to each specific problem on this list. You can use Quick Text entries to simplify data entry in the assessment text fields.

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Entering an Assessment and Plan in Response to the Problem List

If your template supports it, you can enter your plan for responding to all assessments on your patient’s problem list. In the default progress note templates provided with NoteWriter, an empty text field is provided for this purpose, which is located at the bottom of the tab associated with the assessment/plan portion of the progress note. To promote accuracy and consistency for documentation related to high-risk diseases and problems, some diagnoses may require Assessment and Plan information. If you have selected a diagnosis that is configured as high-risk, the Assessment and Plan field becomes required (*) and the Quick Text list pop-up displays automatically to indicate that you must provide an entry in the Assessment and Plan field. Diagnoses that are classified as high-risk are configured by your System Administrator and require Assessment and Plan information in order to save the note. As with all empty text fields in a note template, you can use Quick Text entries to simplify data entry in the plan text field. Quick Text Groups can be created and linked to a High-Risk Diagnosis category so that Quick Text entries can be organized under a Group that has been specifically created for each high-risk diagnosis. When a problem is selected that is classified as high-risk, only relevant Quick Text that is associated with that High-Risk Diagnosis is displayed.

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Entering Service Levels for Billing

If your template supports it, you might be prompted to enter basic service-level data. It typically contains items such as time spent with patient, attestations, and/or the ability to access CPT Codes if Charge Capture is enabled. Your institution might require such data before it can enter charges and process billing data from your patient visit. In the case of the default progress note templates that are provided with NoteWriter, this data is organized under a Billing tab.

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Entering and Validating Charges

If your administrator has configured NoteWriter to work with the Commure Pro Desktop Charge Capture application, you can also enter charges for each of your patient visits. This module can be integrated so that you enter charges as part of your NoteWriter workflow. When implemented, an Add Charge section is present on the note template. You can access the Add Charge section of the template and enter any type of charge, for any type of visit. See Entering Charges Using the Add Charge Section for instructions how to do so. In some configurations, you are required to enter charges in this section before you can sign your notes. Your administrator may have also configured the optional E & M Charge Validation feature to help facilitate the entry of E & M charge codes for subsequent hospital care (CPT codes 99231, 99232, and 99233) or for initial hospital care (CPT codes 99221, 99222, and 99223). When this feature is enabled, a View Charge Validation button is included in your template (Progress Note if subsequent care, H & P template if initial care). When this feature is enabled, a View Charge Validation button is included in your template (Progress Note if subsequent care, H & P template if initial care). This feature evaluates whether the information that you have documented in your template is sufficient to support the entry of any of the three levels of charge codes. If your administrator has enabled this feature, keep in mind that it can only be used when completing a Progress Note for subsequent hospital care or an H & P template for initial hospital care. See Entering Charges for Progress Notes Using Evaluation & Management Charge Validation and Entering Charges Into an H & P Template Using Evaluation & Management Charge Validation for more information about using this feature.

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Entering Charges Using the Add Charge Section

You can use the Add Charge section to enter any type of charge, for any type of visit. The Add Charge section is typically configured as the last section of the note template.

1. Select the Add Charge section of your note. The Charge Transaction screen opens. Some of the data on this screen may already be completed:
   • In the CHARGE DETAILS section, some or all of the fields may be automatically populated.
   • In Selected Codes section on the right side of the screen, under DIAGNOSES, any problems that you entered on the A/P (Assessment & Plan) portion of your note, or that were used on the patient’s last charge transaction, may be automatically entered for you (this depends on your user preference settings).
2. In the center area of the screen, select the charge and diagnosis code(s) that are appropriate for the patient. You can use any of the available methods for charge entry in Desktop Charge Capture, such as Searching for charges or diagnoses, or selecting from the patient’s Existing list (for diagnoses), or selecting from the Favorites or Department categories.
3. Make any other modifications to the Charge Transaction screen as necessary, such as entering/modifying the Charge Details, or entering comments. If the screen you are using is too narrow to fit all the content that displays in one view, a horizontal scrollbar becomes available at the bottom of the screen.

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Entering Charges for Progress Notes Using Evaluation & Management Charge Validation

If your organization has enabled Evaluation & Management (E & M) Charge Validation for subsequent hospital care, your standard Progress Note template includes a View Charge Validation button. The View Charge Validation button evaluates whether the information that you have documented in your Progress Note is sufficient to support the entry of any of the three levels of charge codes for subsequent hospital care (CPT codes 99231, 99232, 99233).

1. Enter information into your Progress Note as usual.
2. Click the View Charge Validation button.
   If the template has only two sections (Note and Add Charge), the button is located at the bottom of the Note section. If the template has multiple sections (Subject, Exam, Data, A/P, Billing, and Add Charge), the button is located in the Billing section.
   The Charge Code Validation window is displayed. This window contains a table, with the three levels of E & M charge codes for a subsequent hospital visit listed in the left column. The other columns contain the factors from the Progress Note that are evaluated when validating the charge code levels. Three main components are evaluated:
   • HPI (History of Present Illness): This component consists of HPI (HPI Review), PFSH (Past Family/Social History Taken), and ROS (Review of Systems). The criteria in all three of these must be met in order for the HPI component to be met.
   • Exam (Exam of body areas or organ systems)
   • Decision Making (Level of Decision Making)
   Time is shown in the last column for informational purposes only. It is not used in validating the charge. If the content of your note indicates that you fulfilled the criteria for an individual factor, a green bullet is displayed next to it. If you met the criteria for at least two of the three main components, a green checkmark is listed next to the charge code, indicating that your documentation supports its selection. In some cases, you may have met the requirements for more than one level of the charge code.
3. Select the appropriate charge code for the patient by clicking on the charge code itself. You can select any charge code — you are not restricted to selecting only the ones that have green checkmarks. The Charge Transaction screen opens. Some of the data on this screen may already be completed:
   • In the CHARGE DETAILS section, some or all of the fields may be automatically populated.
   • In Selected Codes section on the right side of the screen, under DIAGNOSES, any problems that you entered on the A/P (Assessment & Plan) portion of your note, or that were used on the patient’s last charge transaction, may be automatically entered for you (this depends on your user preference settings).
   • In the Selected Codes section on the right side of the screen, under CHARGES, the charge code that you selected from the Charge Code Validation screen is automatically entered for you.
4. Make any other modifications to the Charge Transaction screen as necessary, such as entering/modifying the Charge Details fields, entering more charge codes for additional services, entering more diagnoses, or entering comments.

At any point, you can go back to previous sections of your Progress Note, make changes that might impact the charge validation, and the click the View Charge Validation button again. The updated documentation is evaluated and new/different charge codes may have a green checkmark. You can select a different charge code if necessary. However, this will add a second code to the Charge Transaction screen when it opens. Be sure to delete the charge code that you no longer want.

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Entering Charges Into an H & P Template Using Evaluation & Management Charge Validation

If your organization enables Evaluation & Management (E & M) Charge Validation for initial hospital care, your standard History & Physical template includes a View Charge Validation button and may be configured to capture additional fields to support the charge validation logic. The View Charge Validation button evaluates whether the information that you have documented in the History & Physical template qualifies for any of the three levels of charge codes for initial hospital care (CPT codes 99221, 99222, 99223).

1. Enter information into the History & Physical as usual. Fields that you capture (such as family/social history, review of systems, or exam) are factored in to the evaluation and management logic.
2. Click the View Charge Validation button.
   If the template has only two sections (Note and Add Charge), this button displays at the bottom of the Note section. If the template has multiple sections (History, Family/Social History, ROS, Exam, Diagnostics, A/P, and Add Charge), the button displays under the Billing tab.
   The Charge Code Validation window displays, which provides a table providing the three levels of E & M validation available. The three charge codes for initial hospital visits are listed in the left column. The other columns contain the factors from the H & P template that are evaluated when validating the charge code levels. Three main components are evaluated:
   • HPI (History of Present Illness): This component consists of HPI (HPI Review), PFSH (Past Family/Social History Taken), and ROS (Review of Systems). The criteria in all three of these must be met in order for the HPI component to be met.
   • Exam (Exam of body areas or organ systems)
   • Decision Making (Level of Decision Making)
   Time is shown in the last column for informational purposes only. It is not used in validating the charge. If the data you entered in your note qualifies for an individual factor, a green bullet displayed next to the associated table entry. If the data you entered in your note qualifies for two of the three main components, a green checkmark displays to the left of the charge code, indicating that your documentation supports its selection. In some cases, you might meet requirements for more than one charge code level.
3. Select the appropriate charge code for the patient by clicking on the charge code itself. You can select any charge code — you are not restricted to selecting a particular entry. Note that the green checkmarks are used to help guide you in selecting the most appropriate code only; you can choose other codes from the menu if you decide that the level of care you provided warrants a higher or lower acuity level. The Charge Transaction screen opens. Some of the data on this screen may already be completed:
   • In the CHARGE DETAILS section, some or all of the fields may be automatically populated.
   • In Selected Codes section on the right side of the screen, under DIAGNOSES, any problems that you entered on the A/P (Assessment & Plan) portion of your note, or that were used on the patient’s last charge transaction, may be automatically entered for you (this depends on your user preference settings).
   • In the Selected Codes section on the right side of the screen, under CHARGES, the charge code that you selected from the Charge Code Validation screen is automatically entered for you.
4. Make any other modifications to the Charge Transaction screen as necessary, such as entering/modifying the Charge Details fields, entering more charge codes for additional services, entering more diagnoses, or entering comments.

At any point, you can go back to previous sections of your H&P template, make changes that might impact the charge validation, and the click the View Charge Validation button again. The updated documentation is evaluated and new/different charge codes may have a green checkmark. You can select a different charge code if necessary. However, this will add a second code to the Charge Transaction screen when it opens. Be sure to delete the charge code that you no longer want.

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Entering and Submitting Orders Using CPOE

If your administrator has configured NoteWriter to work with the Commure Pro Computerized Physician Order Entry (CPOE) application, you can also enter orders for each of your eligible patient visits. The CPOE module is now integrated with NoteWriter so that you can enter patient orders as part of the note creation work flow. When CPOE is implemented, an Enter Orders tab displays as part of the note template. You can access the order entry section of the template and enter orders from within the NoteWriter template just as you would enter orders directly from the CPOE application. The determination to display an Add Orders tab within the NoteWriter template is made each time that a user chooses a visit from the Select a Visit drop-down menu. When the user selects a visit that is eligible for order entry and then chooses a template that supports CPOE, the Enter Orders tab is added to the left of the note template wizard. From the Enter Orders tab, users can enter orders as part of their NoteWriter work flow, without needing to navigate outside of the NoteWriter template to access the CPOE application. Note that the rules for selecting the default visit are determined by the CPOE application and not by the rules that normally govern default visit selection in NoteWriter. When draft orders exist for the selected patient, users opening a note are taken immediately to the Enter Orders tab (except on the iPad, where notes always default to display the first tab). When users with un-submitted orders click the Save as Draft button, note that they are also taken to the Enter Orders tab and a confirmation message asks if the user wants to save the orders and note as a draft, to be finished later. Management of order submissions from CPOE is handled independently from note submissions; unless clinicians choose the Save as Draft option (which saves current drafts of both order session and note). When clinicians click the Sign / Submit button for notes that have associated orders, they are prompted to enter their PIN/password and are then prompted to complete any required fields, regardless of whether there are also orders associated with this note submission. When users click the Sign / Submit button for orders, they are informed as to whether there were new orders submitted in the session, regardless of whether the NoteWriter application is active or grayed-out. When users with pending orders attempt to switch to a different visit, they are prompted with the confirmation message “Order have already been added to this session. If you change the visit those orders will be discarded”. They can respond to this message by proceeding with the change of visit or by canceling out of the change to complete order entry for the current visit.

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Entering Data in Split Screen View using Pop-Out Mode

You may find it helpful to review a patient’s clinical data while writing a note. The NoteWriter screen has a Pop-Out mode that allows you see both the clinical data and your note template side-by-side on the same screen (or even extend the NoteWriter screen to an external monitor). To open NoteWriter in Pop-Out mode:

1. Start a new note (see Starting a Note) or open a draft note (see Modifying New or Draft Notes).
2. In the top-right corner of the NoteWriter screen, click the Pop-Out button . NoteWriter opens in a new window, which you can move and resize.
3. To return to a single screen, click the Pop-In button.

Show Settings that control this feature

• Admin - User - NoteWriter - Always Display Note Entry in Pop-Out Mode
• Admin - User - NoteWriter -Set Clinical Data Percent Width in Pop-Out Mode

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Saving Draft Notes

Typically, working on a note involves some combination of documenting the patient’s condition, entering clinical data pertaining to the patient visit, and (optionally) entering any charges from the visit (if you are using the Charge Capture application). Once you launch a note and start entering your patient data, you can then save your note in draft form at any time. Notes in draft status are created in any of the following circumstances:

• You clicked the Save as Draft button to save a note as a draft.
• You clicked outside of the NoteWriter interface. For example, you navigated away from NoteWriter to look at another Commure Pro module.
• You logged out of the Physician Portal without manually saving a note as a draft. In this case, an auto-saved version of the note is saved as a draft note.

After you save a note as draft, it displays on the Clinical Notes page with the identifier DRAFT pre-pended to its name in the Clinical Notes list. In addition, draft notes are identified as such in the note header, which displays either in the right-hand side of the Clinical Notes display or below the list of Clinical notes depending on how your administrator set up the view, when you select the note from the list. As you save draft notes you will see a notice at the top of the Physician Portal screen stating You have unfinished item(s): and then the number and kind of unfinished item is displayed as a link. For draft notes, you will see X draft notes where X is the number of draft notes. Each time that you save a new note as a draft, the number of draft notes displayed at the top of the Physician Portal screen is incremented by one to indicate the total number of notes that remain in draft status for the current user. Notes in draft form are visible to their author only; other providers in your department or institution do not see your notes displayed on their Clinical Notes list until you sign them. Before signing a note, you must review and complete any unfinished data in the note, preview the note for any omissions or errors, and (optionally) double-check to ensure that the charges you entered are accurate. Once you sign a note, it becomes final and you cannot make additional edits to it. After you sign a note, the note is made visible to all providers in your department on the Clinical Notes list. In addition, the draft note link on this screen is updated to reflect the adjusted cumulative total of notes that remain in draft status. To save a note in draft form, you must have the note template open in the NoteWriter interface. To save a note as draft:

1. Click the Save as Draft button that displays at the bottom of each note template. A confirmation dialog box displays
2. Click Yes to save the note in draft form. After a brief message displays to indicate that the note is being saved, the NoteWriter interface is closed and you are returned to the Patient List view in the Physician Portal.

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Manually Saving Notes

As you add to your note, you can manually save your information by clicking Save at the bottom left corner of the note screen. If you should accidentally cancel out of the note, all information that was manually saved is kept.

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Auto-Saved Notes

Notes in progress are auto-saved at intervals that are configured by your administrator. Typically, you will manually save your notes as drafts as you continue to work on them, so you may not need to frequently access auto-saved versions of your note. However, there may be occasions where you want to revert back to an earlier, auto-saved version of a note in progress, such as after a system failure. The following rules govern the auto-save behavior of notes in progress.

• Auto-Save and Unexpected Outages: The auto-save feature is principally designed to enable users to recover a temporary version of a note in the event of an unexpected system failure or outage. When you log-in after such an event and re-open your note, your system may be configured to prompt you to choose between the auto-saved version of the note and the last copy that you saved manually. Alternatively, your administrator may have configured your system to always use the last auto-saved version of the note.
• Auto-Save and Canceling a New Note: When you start a new note that is auto-saved while you edit it, but you manually cancel out of the note before saving it in draft form at least once, the note is deleted, including the auto-saved version.
• Auto-Save and Canceling a Saved Note: When you open a draft note that is auto-saved while you make new edits to it, but you manually cancel out of the note before saving the updated version, the note reverts back to the previous manually saved version the next time that you open it.

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Working with Draft Notes

NoteWriter is designed to be flexible, so that providers can create and maintain notes in a variety of situations and clinical settings. This flexibility enables providers to easily navigate between their note and other areas of the Physician Portal with a minimum of clicking. Providers can also record notes in the face of frequent interruptions, since the NoteWriter interface enables them to create and maintain many types of notes, store these notes in draft form, and sign them at a convenient time. While the application provides the flexibility needed to accommodate a wide variety of workflows, this flexibility does not extend to the output of your notes. Instead, the print output of notes is standardized in NoteWriter, so that each note type is structured in a uniform way, regardless of the workflow you followed when creating it. This uniformity enables providers to more easily work with signed notes, since they can reference all of their note data with predictability and ease.

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Previewing and Printing Draft Notes

You can preview and print a note at any time during the note creation process, from the time you start entering patient data into the note until you sign it. By previewing a note, you can review your notes for completeness and accuracy before you sign them. The print output of notes is standardized in NoteWriter, so that each note type is structured in a uniform way, regardless of the workflow used to create it. To preview a note, you must have the note template open in the NoteWriter interface. To preview and print a note:

1. Click the Print Preview button that displays at the bottom of each note template. The note displays on the screen in print format, enabling you to view the note as it would look if you were to sign and print it.
2. Hover over the bottom center section of the screen to display the Save, Print, Zoom, and PDF icons. Click the Print icon if you want to print a draft copy of the note. If you clicked Print icon, the print dialog box opens, and you are prompted to select the printer you want. You may also be prompted to select a print format, if multiple formats have been provided for your note type. Alternatively, you can click Close to return to the note template screen without printing a draft copy.
3. Select the printer you want, and click Print. The draft note is sent to the printer. The identifier “DRAFT” displays in the footer of the printed document so that you can easily differentiate draft copies of a note from final copies.

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Modifying New or Draft Notes

You can edit or cancel a newly-created or draft note, as well as delete draft notes from your list of notes.

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Editing Notes

You can edit data in a note at any time, provided you are the author of the note, the note is in draft status (either as a new note or as a saved draft), and the note was created using the Commure Pro NoteWriter application. You can always edit the following data in draft notes, regardless of how your administrator configures your application:

• Patient visit: All patient visits are displayed in a drop-down list. When you select a different patient visit, all default visit-related template fields update automatically. Fields in which you have specified a different value are left as-is.
• Note date and time: Note date and time are editable fields in the note, depending on the timeframe of the visit.
• Template data: Template data varies by institution, but this data may include text descriptions of a patient’s condition or status, ROS data, clinical data, such as lab and test data, duration of a visit, and data related to billing.

To edit a note that you have saved as a draft:

1. Click on the draft notes link displayed at the top of the Physician Portal screen.
   The number in this link represents the total number of notes that you have in draft status for your patient list. If you currently do not have notes in draft status, no draft notes link displays.
   A list appears, displaying all of your notes (and note addenda) that are in draft status.
2. Click Edit in the row corresponding with the note you want to edit. The note template opens to the most recent section of the note you worked on and you can begin making changes to your note.

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Editing a Note from the Clinical Notes List

Alternatively, you can edit draft notes directly from the Clinical Notes list. To edit a note from the Clinical Notes list:

1. From the Patient List tab, click on the Clinical Notes display item. The Clinical Notes list displays.
2. Click on any note identified by the term DRAFT (with the icon). A few note details (note author, status, date and time of note) are displayed in the note details screen either on the right-hand side of the screen or under the list of Clinical Notes, along with options to edit or delete the note.
   These options display for the note author only.
3. Click the Edit button. The note template opens to the most recent section of the note you worked on and you can begin making changes to the note.

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Canceling Draft Notes

When you cancel a draft note, the NoteWriter interface is closed, and you are returned to the Patient List that displays in the Physician Portal. If you have already saved your note in draft form, the note reverts back to the most recent version saved the next time that you open it. If you have not yet saved your note, the note is deleted, including any versions of the note that were saved automatically by the auto-save feature. To cancel out of a note, you must have a note template open in the NoteWriter interface. To cancel out of a note:

1. Click the Cancel button that displays at the bottom of each note template. A confirmation dialog box displays.
2. Click Yes to cancel out of the note. The note template closes, and you are returned to the Patient List. If you did not previously save the note (using either the Save icon or Save as Draft button), it is deleted, including any versions that had been auto-saved. For more information, see Auto-Saved Notes.

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Deleting a Draft Note

Deleting a note removes a note that you have saved in draft form. Each time that you delete a draft note, the number associated with the draft notes link is decremented by one to reflect the change. To delete a note that you have saved as a draft:

1. Click on the X draft notes link displayed at the top of the Physician Portal screen. A list appears, displaying all of your notes that are in draft status.
2. Click the Delete button in the row corresponding to the note you want to delete. A confirmation box displays.
3. Click Yes to delete the note. The draft note is deleted. Once a note is deleted, you cannot recover it.
   You cannot delete notes that have been signed. Signed notes are considered final.

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Deleting a Draft Note from the Clinical Notes List

Alternatively, you can delete draft notes directly from the Clinical Notes list. To delete a note from the Clinical Notes list:

1. From the Patient List tab, click on the Clinical Notes display item. The Clinical Notes list is displayed.
2. Click on any note identified by the term DRAFT (with the icon). Options for editing or deleting notes are provided on the right-hand side of the screen, next to each note.
   These options display for the note author only.
3. Click the Delete button. The draft note is deleted. Once a note is deleted, you cannot recover it.
   You cannot delete notes that have been signed. Signed notes are considered final.

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Shared Draft Notes

Draft notes may be shared to enable care team members (where allowed), to show drafts to other team members caring for a patient, without requiring a signed or final note. When a Resident/Mid-level elects to share a draft note, they do it with a co-signing Attending provider for viewing, or for editing, depending on permissions. When an Attending provider elects to share a draft note, if allowed, the note is shared to All for viewing only. The following sharing options are available:

• Sharing to a co-signer for viewing only. For example, mid-level or residents might want to share their note with their teaching physician to get feedback on the note content so that they can edit before signing.
• Sharing to a co-signer with editing capability. This allows the Attending to add to the note before it is signed.
• Sharing to a co-signer with editing capability, and non-editing viewing capability to All. Sharing to All allows continuity of care, such as for shift changes, so other providers can track patient care.

Shared drafts are indicated as such in note search in the Status column, and in the Inbox in the Status column (along with the S designation on the left of the listing, showing that the note is shared). If a Shared Draft is selected as part of multi-selecting drafts, the Delete button on screen is disabled to prevent removal of the Shared Draft, as Shared Drafts cannot be deleted. Note sharing must be enabled for a user as this functionality is off by default. This can be configured for individual users or via Bulk User Settings.

Show Settings that control this feature

• Admin - User - NoteWriter - Allow user to share draft notes
• Admin - Institution - NoteWriter - Allow co-signing physician to edit resident shared drafts
• Admin - Institution - NoteWriter - Allow shared drafts for residents/mid-levels to be viewed by all users

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Shared Drafts for Residents/Mid-levels

When the Resident/Mid-level is allowed to share a draft, the Share Draft button appears on the note display. Selecting Share Draft displays a popup to enter the co-signature provider name to share with. Enter a provider name in the field and select OK. When a note is shared with a co-signer (displayed with an S to designate Shared, as opposed to the D for Draft), it appears in the Inbox of the note author and designated co-signer. If the co-signing physician is enabled for editing and makes an update, a vertical blue bar displays for the note in the Inbox of the note author, to show it has been edited.

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Shared Drafts for Attending Providers

The note status for the Attending co-signer is highlighted in yellow in the note details section of the patient display. The attending co-signing physician (if enabled) may be able to add to a shared note, but not decline or sign it, as signing the note is required by the note author (the Sign button is disabled for the co-signer in this case). If another user shares their note while the provider is using Commure Pro, the draft note count does not reflect the other user’s share until the provider saves or deletes a note. For the Inbox, the provider must refresh/navigate to a folder before the other’s share is included.

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Shared Drafts for Viewing by All

When a note has been shared for viewing by all, the status is highlighted, with the draft watermark. Other providers may view the draft, but not edit it.

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Shared Draft Addendum

An addendum can be filed as a shared draft. For note addenda, once a draft addendum/note is shared, the Save Draft button is disabled. A Shared Draft Note Addendum has similar restrictions and functionality as shared draft notes, including the following:

• The addendum displays with the yellow banner and “shared draft” status.
• The addendum may not be deleted.
• The addendum, when completed, is sent in Final status.

Shared drafts may be configured to be sent to your EMR, depending on your EMR and site configuration. For more information on this option, contact your Commure Pro representative.

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Scribe

A Scribe (with a special type of shared draft status) is a Commure Pro user who follows certain physicians through their visits and documents on their behalf. A Scribe can be assigned to one or more physician, or be designated to scribe for any physician. The Scribe can create a note (based on the same templates as used by the physician) and choose to save as a draft (for later editing or deleting) or sign it. The Scribe draft document is not shared with other Commure Pro users. When the Scribe signs, the note is not final, and is not sent to your EHR, but routed to the designated physician to review and sign off on. Though the Scribe creates the note (using the same templates as configured for the physician), the physician is designated as the note author, and is the one who completes the note, with full access to edit the scribed note. Scribes should be configured to use a templated addendum, which allows the existing co-signature/scribe workflows to be used with routing the templated addendum to the physician to sign, and for the physician to edit the addendum.

Show Settings that control this feature:

• Admin - User - NoteWriter - Scribe User
• Admin - User - NoteWriter - All Templates Require Co-Signature/Scribe
• Admin - User - NoteWriter - Select Templates Requiring Co-Signature/Scribe
• Admin - User - NoteWriter - Restrict Co-Signature/Scribe to Department
• Admin - User - NoteWriter - Restrict Co-Signature/Scribe to Providers

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Using Scribe

Once a Scribe has been set up with permissions, co-signing physicians, and available templates, they may begin creating notes. To write a Scribed note:

1. Select a patient from the list, and click the Plus sign to write a note.
2. Select a template for the note type from the displayed list.
3. From the Select Signing Physician pop-up, click in the search field and begin entering the desired physician’s last name. When enough of a name match is made, the physician name appears, or if there is more than one, a drop-down list is displayed. Click on a physician name to select and click Confirm.
4. The note opens. Complete the note and click Save Draft for later editing (or deleting), or Sign, to end the Scribe portion and send the note on to the co-signing physician for review, editing, or note completion.
   • If selecting Save Draft, a confirmation pop-up appears. Click Yes. The Scribe can later edit (or delete) the note, and can edit their note until the physician edits or signs it. If for some reason the scribe opens and resaves the document multiple times, only the most recent date/time and signature line displays on the note detail view, although each instance of submit is audited in the Commure Pro audit trail.
   • A Draft Scribe note remains in the Scribe (and physician’s) Inbox queue until signed, with a Status of Yes in the Scribe column, and the Authoring physician’s name.
   • Scribed notes are designated as such in the Scribed column in the Inbox, which only displays if there are any notes from scribes.
5. Once a Scribe selects to Sign a note, a confirmation pop-up appears, alerting that once signed, the Scribe can no longer edit the note. Click OK to Save or Cancel to return to the note. When the Scribe signs, their portion is done, and it no longer appears in their Inbox, but is displayed in the co-signing physicians Inbox (in the Co-Sign category in their list), as well as on the list of notes for the patient, with the Scribe’s name and a status of “Scribed: Awaiting Signature,” also displaying the name of the physician author. The physician opens the note and has the following options:
   • Reassign- Allows the physician to reassign the note from themselves to another physician, using standard co-signature functionality.
   • Decline- If the physician declines to sign the note, it is returned to the Scribe’s Inbox for further processing.
   • Delete- Deletes the note.
   • Skip- Skips the note and goes on to the next. When this is the last note in the list, a pop informs that this is the end of the Inbox.
   • Attest- Allows you to edit the note before selecting Sign/Submit (making the note Final) or Save as a draft.
   If a physician makes unsaved edits and comes back to the note, they are prompted to Keep or Discard the edits. If a physician edits and saves a Scribed note as a draft, the Scribe can no longer edit it.
   • When saving, the physician is queried for a pin/password (if enabled), and the document is sent to the EMR and placed in “final” status. The “awaiting co-signature” status is removed.
   • The physician signature line and attestation is included in the note content.
   Example of signature after both the attending and the scribe have completed their signatures: Electronically signed by NOLAN, GRACE on 09/04/18 at 01:46PM Electronically scribed by SMITH, JOSEPH on behalf of NOLAN, GRACE at 09/04/18 at 01:40PM

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Signing Notes

The process of signing a note is final; once you click the Sign/Submit button, you cannot make additional edits to your note, so save your notes in draft form until you are certain that they are complete and accurate. Due to the finality of the signing process, your administrator may decide to prompt you for a password or PIN when you attempt to sign your notes. If you do not have the correct password or PIN, contact your administrator for these credentials. If you are prompted for:

• Password—You must enter your Commure Pro password before your notes are considered final.
• PIN— You must enter your Meditech PIN before your notes are considered final.

Once you sign a note, your electronic signature is added to the last page of the finalized note. Electronic signatures include your first and last name, as well as the date and local time that you signed the note. For example: <Electronically Signed by Dr. David Livingstone on 9/24/2010 at 8:28 AM> To sign a note, you must have a note template open in the NoteWriter interface. To sign a note:

1. Click the Sign/Submit button that displays at the bottom of each page of your note template. You may be prompted to enter credentials to validate your identity. In addition, you may be prompted to confirm that you want to sign your note.
2. (Optional) If prompted, enter the following information:
   • PIN: Enter your PIN, which validates your credentials on a MEDITECH system.
   • Password: Enter your password, which validates your credentials on the Commure Pro system.
   If prompted to confirm, click Yes to indicate that you want to sign the note. The note is finalized, and your electronic signature is added to the last page of the finalized note. The note is added to the Clinical Notes list as a final note, and you can no longer make changes to it. If the note had been saved in draft status before you signed it, the pre-pended DRAFT identifier is removed from the note name in the Clinical Notes list. In addition, the draft note link in the Physician Portal is decremented by one to reflect this status change. If you are required to get co-signature for notes, you are prompted to select from a list of clinicians who are authorized to co-sign your note (as defined by your administrator). Upon signing and submitting your note, the note is sent to the co-signing provider’s Inbox to be approved or declined. Once approved by an authorized provider, co-signed notes display on your list, identified by the co-signing provider. In the event that the co-signing provider declines the note, the note displays on the clinical notes list with a (yellow) highlight applied to the header to identify the declined status. The header also includes the name of the declining provider and the reason for declining the note.

After signing the note, you may be prompted either to print your note or to enter associated charges, if your administrator has configured NoteWriter for either of these additional steps.

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Printing Signed Notes

Once you sign a note and it becomes final, you can print it from the Clinical Notes list on the Physician Portal. Note that the print output of notes is standardized in NoteWriter, so that each note type is structured in a uniform way according to its template, regardless of the workflow you followed when creating it. You may also be prompted to print your note upon signing it, if your administrator has configured NoteWriter to do this. To print a signed note:

1. From the Patient List tab on the Physician Portal, click on the patient name whose note you want to print.
2. Click on the Clinical Notes link to navigate to the Clinical Notes display.
3. From the Clinical Notes list, click on the name of the note you want to print. The note displays in the Clinical Notes screen.
4. Click Print , displayed in the upper right-hand corner of the note header, to the right of the Search text box. The note opens in your default browser, and you are prompted to select the printer you want from a print dialog box. You may also be prompted to select a print format, if multiple formats have been provided for your note type.
5. Select the printer you want, and click Print. The signed note is sent to the printer.

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Canceling Signed Notes

If enabled by their configuration, clinicians have the option to cancel notes that they have already signed and submitted. Functionality for canceling signed notes supports a clinician’s need to undo certain notes created in error, such as after entering notes on the wrong patient. When granted permission to cancel signed notes, clinicians have access to a Cancel Note button on the Clinical Notes module. The length of time that clinicians have to cancel signed notes is configurable by their administrator Canceled notes remain on the Clinical Notes list, but the note contents display with strike-through text to identify these as canceled by the clinician. If clinicians are required (by configuration) to specify a reason for canceling their note, this reason displays toward the top of the note.

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Adding an Addendum to Completed Notes

Clinicians who find themselves needing to clarify or supplement information from a note that they already signed and submitted can create an addendum to document and append this additional information to their original note. When they select their (completed) note from the Clinical Notes pane, authorized clinicians can click the Add Addendum button from the lower-right portion of the screen. Note that clinicians must be authorized in order to create addenda for their completed notes. Also note that display of the addendum tab requires templates that support this functionality. If authorized clinicians cannot see the Add Addendum button listed among the available options, contact your Commure Pro representative. You must update any of the standard templates for which you want use addenda, and then enable this functionality for the templates that you want to use with the capability of adding an addendum. The Addendum tab displays the entire contents of the completed note in preview mode, enabling clinicians to reference this information as they enter additional information into Addendum Comments text field. Note that the NoteWriter application supports the use of addenda with any of the five standard templates described in the preceding sections of this chapter. After clinicians sign and submit notes with an addendum, the addendum displays above the original note content on the standard note templates. Just as with regular notes, clinicians can preview their addenda or save unfinished addenda in draft form. Draft addenda display as additional entries in the Notes in Draft Status window that clinicians see when they access their draft notes from the Unfinished Item(s) banner at the top of the portal. After clinicians sign and submit notes with an addendum, the addendum displays above the original note content on the standard note templates. Mid-level clinicians (such as Nurse Practitioners or Physician Assistants) requiring note co-signature are also subject to the same co-signature restrictions when adding and submitting addenda to their notes. For addenda co-signature, each addendum is configured on a per-template basis (by your administrator) so that addendum selection is automatic based on the template in use. Upon clicking the Add Addendum button, mid-level clinicians can enter any supplementary content and then submit their addendum, which is then sent to the authorized co-signing clinician(s). While in a pending state awaiting co-signer approval, a submitted addendum displays below its associated template on the Clinical Notes list, identified by addendum name and author (date / time stamp of addendum submission is omitted from the display). Once signed, an addendum becomes part of its template and no longer displays separately on the Clinical Notes list. Once you start to create and use addenda with some frequency, you can then carry forward content from past addenda using the “Insert Previous” feature, which functions the same whether it be used with notes or note addenda. Your institution can choose to display the addendum entry box either above or below the original note content.

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Authorizing Users to Create Addenda for Completed Notes

Clinicians can be authorized to enter note addenda in one of two ways:

• They belong to the list of authorized providers who can enter note addenda
• They belong to the list of authorized departments that can enter note addenda

Options for configuring both of these lists are provided from the NoteWriter (user) Settings screen. To enable users to enter addenda for notes that were already signed and submitted:

1. Click the Admin tab and then the User tab. The list of available users displays.
2. Select the user you want and click the Edit button.
3. Select NoteWriter from the Edit Settings drop-down menu.
4. From the NoteWriter Settings screen, locate the two settings Restrict Addendum to Providers and Restrict Addendum to Department.
5. Click the Edit button associated with either of these two settings and use the checkboxes to select the providers or departments that you want to authorize to enter note addenda.
6. Click Save. The option to create addenda for completed notes will be restricted to this list of providers or departments. Note that any authentication requirements are enforced whenever clinicians create addenda for notes and for newly created users. Upon signing and submitting an addendum, users are prompted to validate with password or PIN (if their institution is configured to require authentication using password or PIN).

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Configuring the Duration that Addenda Can be Entered for Completed Notes

To configure the duration that clinicians have available to enter addenda for notes that have been signed and submitted:

1. Click Admin > Institution > NoteWriter > Addendum Timeframe in Days and enter a number within the allowed range (0 - 999).
2. Click Save. The option to create addenda for completed notes is available for this number of days after notes have been signed and submitted. This option is only available to authorized clinicians, and only if your institution or facility has updated your NoteWriter templates with a version that supports this functionality.

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Managing Quick Text Entry

Once you’ve mastered the most basic workflow for creating a note in the NoteWriter application, you can quickly advance to use NoteWriter’s powerful Quick Text entry features. Quick Text entries can be defined by your department administrator, so that all providers within your department share a standardized Quick Text vocabulary. You can also define your own Quick Text entries, which only you can access. In addition to using any Quick Text entries that have been defined for your department, you can create additional groups and entries for your own use. The ability to create your own groups and entries enables you to personalize your Quick Text vocabulary of terms for a specialty or individual work style. You can define these groups and entries at the outset, using past experience to anticipate the terms or longer standardized text that you frequently encounter when documenting patient encounters, or define “on the fly,” as the need arises.

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Creating and Managing Quick Text Groups and Entries

You can define Quick Text groups and entries at the outset, using past experience to anticipate the terms or longer standardized text that you frequently encounter when documenting patient encounters, or define “on the fly,” as the need arises.

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Creating a Quick Text Group

Quick Text groups are a way to organize your Quick Text entries and group similar or frequently used entries. To create a Quick Text Group:

1. Click the Quick Text icon to display the Insert Quick Text window.
2. From the Insert Quick Text window, click the Manage Quick Text button . The Add Quick Text window displays.
3. Enter a name into the Name field.
4. Next to the Is This a Group? setting, select Yes to create a Group.
5. (Optional) If High-Risk Diagnoses is enabled for your site, then the Link to Diagnosis Group drop-down displays. If you are creating a Quick Text Group for a high-risk diagnosis category, select the category from the drop-down list.
6. Select Save. Your group is added to the list on the left side of the screen, and displays as a blue header. Note that these headers also behave as folders that you can sort, expand and collapse. As you add Quick Text entries, you can categorize all related entries under a group, giving you the option to show or hide all related entries at a glance.

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Creating a Quick Text Group for a High-Risk Diagnosis Category

Some problems and associated diagnoses may be deemed high-risk, and benefit from specific and consistent Assessment and Plan information. To accurately document high-risk problems, specific diagnoses can be configured by your System Administrator to require Assessment and Plan documentation when they are selected in a History and Physical note, and also prompt users with Quick Text that has been created for that high-risk diagnosis. In order for users to be prompted with Quick Text entries that are specific to a high-risk diagnosis they have selected, a Quick Text Group must be created and linked to a High-Risk Diagnosis category, and then Quick Text entires must be created and added to the group. This procedure describes creating the Quick Text Group and linking it to a high-risk diagnosis category so that Quick Text entries can be added to it. To create a Quick Text Group for high-risk diagnoses:

1. Click the Quick Text icon to display the Insert Quick Text window.
2. From the Insert Quick Text window, click the Manage Quick Text button . The Add Quick Text window displays.
3. Enter a name in the Name field.
4. Next to the setting Is This a Group?, select Yes to create a Group.
5. If High-Risk Diagnoses are enabled for your site, then the Link to Diagnosis Group drop-down displays. This drop-down lists the Diagnosis Groups that have been defined as high-risk categories by your System Administrator.
6. To link the new Group to a Diagnosis Group that has been defined as a high-risk category, select the Diagnosis Group you want from the drop-down list.
7. Select Save. Your group is added to the list on the left side of the screen, and displays as a blue header. Note that these headers also behave as folders that you can sort, expand and collapse. As you add Quick Text entries, you can categorize all related entries under a group, giving you the option to show or hide all related entries at a glance.

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Creating Quick Text Entries

To create Quick Text entries:

1. Click the Quick Text icon + to display the Insert Quick Text window.
2. From the Insert Quick Text window, click the Manage Quick Text button . The Add Quick Text window displays.
3. Enter a name into the Name field.
4. For the Is This a Group? setting, select No.
5. (Optional) Configure any of the following preferences for this Quick Text entry.

   Show Description

   • Shortcut- Specify a keyboard shortcut to insert Quick Text entries directly from your keyboard, using a unique series of keystrokes, without having to use your mouse to navigate to the Quick Text drop-down menu. Keyboard shortcuts require a minimum of two characters, but using three or more can minimize accidental substitutions. Note that only a limited set of punctuation characters are allowed when defining shortcuts. These characters are limited to the most commonly-used characters: period (.), comma (,), question mark (?), and forward slash (/). By remaining mindful of commonly-used key stroke combinations, you can prevent most accidental substitutions. By using a few more characters, you can lessen unwanted substitutions.

   Before you assign keyboard shortcuts to substitute for text field entries, you must define these blocks of text as Quick Text entries.

   • Default- Select this option if you want a specific Quick Text entry to pre-populate a field when clinicians first select and open a note template.
   • Hide From Popup- Select this option for Quick Text entries that you want to hide from the Click to Insert window. This option is especially helpful with Quick Text entries defined at the department level, since individual clinicians might not use specific Quick Text that has been created for other users within their department. Note that any keyboard shortcuts defined for hidden Quick Text entries continue to work as expected, automatically populating the selected field with the entry represented by a specific series of keystrokes.
   • You can type in special characters (#####) or to use the interface to include tags. You can select rich text (default) or a Wiki Source (markup view). If you select the Wiki Source button, use the special characters rather than the UI controls. Selecting the button hides the other formatting options in the Toolbar.

   To the right of the Wiki Source button is an Information icon that displays descriptive markup hints when the cursor moves over it.
6. Select Save when finished.

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Creating Keyboard Shortcuts

Rules for creating a keyboard shortcut:

• Shortcuts must be unique within a group, but you can use the same shortcut in fields belonging to different groups.
• If shortcuts are duplicated between a global Quick Text entry and a (local) entry, note that the local entry is inserted when the cursor is positioned within the associated field, but that elsewhere in notes the identical sequence of keys triggers the global Quick Text entry.
• If shortcuts are duplicated between Quick Text entries at the department and user level, the user-level entry is always given precedence over the department-level entry.

To create a keyboard shortcut:

1. Click the Quick Text icon + to display the Insert Quick Text window.
2. From the Insert Quick Text window, click the Manage Quick Text button . The Add Quick Text window displays.
3. In the Shortcut field, enter the keystrokes that represent a longer term.
   Keyboard shortcuts are not case-sensitive. For example, you can define your shortcut as negctx, then use the shortcut NEGCTX (or any combination of case) interchangeably.
4. Click Save. You are returned to the note template. When the cursor is active in the Patient Narrative text field, entering the keystrokes from your keyboard now triggers insertion of the text string.

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Adding Tags to Include Variables within Quick Text

You can embed pre-defined selection lists and free-text fields directly within any Quick Text entries that you create. These tags allow for the creation of flexible Quick Text that can be adapted to meet a variety of clinical scenarios that all follow a similar process. Using tags helps you to manage your Quick Text entries by allowing for the effective re-use of content, and by reducing the need to create new Quick Text entries when only some of the details need to be modified for a particular clinical situation. Quick Text provides two types of tags that you can embed within your Quick Text entries, accessed from the Toolbar.

• To add a Multiple Choice tag to your Quick Text entry, position your cursor within your Quick Text entry, and click the Insert Single Select icon from within the Toolbar. Upon insertion into Quick Text, the Multiple Choice tag has the label “Select One” by default and is underlined. Once you add a Multiple Choice tag, you can click it to define the choices list and to update the label with text better suited to the context, and which helps instruct clinicians to know to click and select a menu option. The numbered list grows dynamically each time that you add another choice. Clinicians only see the label within the Quick Text, but, upon clicking the tag, will see all of the choices that you have defined for them in this window.
• To add a Free Text tag to your Quick Text entry, position your cursor within your Quick Text entry, and click the Insert Free Text icon from within the Toolbar. Upon insertion into Quick Text, the Free Text tag has the label “Insert Text” by default. Click this tag to update the label with text better suited to the context, and which helps to instruct clinicians to know to click the tag and replace it with a free-text description to complete missing data.

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Sorting Groups in the List

To sort the groups in the list, click the Sort icon in the group list header.

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Deleting Quick Text Groups and Entries

To delete a group from the list, click the group name in the list and click the Trash can icon. To delete an entry from the list, select the item and click the X (Delete) option to the right of the entry. For deleting either a group or an entry, you are prompted to confirm the deletion. Select Yes to confirm the deletion.

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Linking Clinical Data from Other Modules

NoteWriter is designed so that providers can leverage existing data from other modules in the Commure Pro Physician Portal. If your templates support this capability, you can link from within your note template to multiple modules in the Physician Portal without losing your place in the note or link data from multiple modules in the Physician Portal to write a new note. Once you navigate to another module, you can select some or all of the available clinical data to copy into your note, provided your administrator has granted you permission to copy over this data. Templates can be designed to link to one or more of the following modules in the Physician Portal:

• Allergies
• Clinical Notes
• Medications
• Lab Results
• Order Status
• Test Results

The technique used for selecting data from another module is consistent across most of the Physician Portal modules. Exceptions to this rule are the Clinical Notes and Test Results modules, which provide some additional options. Typically, when you click a link in your note template to navigate to another module, you use check boxes to select the items you want to copy over from that particular module. Once you select the items you want to include, you can copy these items to your note with a single click, and you are returned to your note template, where you can select data from additional modules or navigate elsewhere. You can continue to add, remove, and modify clinical data in the note template until you sign a note; once you sign a note, it becomes final and you can no longer make edits to it. For example, if you want to include allergy information in your note, you can link from within your note template to the Allergies module. To add allergy information to your note:

1. Navigate to the section of your note where these links are provided, and click on the link to the Allergies module. The Allergies screen displays, where you are prompted to select from any allergies that pertain to your selected patient.
2. Select any of these allergies to include in your note. Alternatively, you can select every option on the list by clicking the Checkmark icon that displays above the column of check boxes. Clicking this icon a second time de-selects all of the options on the list.
   You can also navigate to any other linked modules from this screen before you. This can save you the step of having to return to your note template if you experience a change in work flow and decide to include a different type of data.
3. Click the Copy to Note button in the lower left-hand corner of the screen to add the data to your note. You are returned back to the place in your note where you selected the Allergies module link. The data displayed for each module is obtained directly from the clinical data stored in the Commure Pro Physician Portal. If changes are made to this data from outside of the note template, these changes are reflected from within a note template view of these modules immediately; the links in NoteWriter templates share the same underlying data as the links that display in the Physician Portal.

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Entering Data from Clinical Notes and Test Results

Entering data from the Clinical Notes and Test Results modules is very similar to entering data from the other Physician Portal modules, but a few differences are noteworthy. When you enter data from these two modules, you have options for the amount of detail to include. You can choose between:

• Including references to one or more documents from these modules

  Hide References to clinical notes

  • Type of clinical note that you are referencing
  • Date that the clinical note was created
  • Author of the clinical note (if the note has been signed)

  Once you add a reference to your note, you can annotate this reference with additional information. For more information, see Adding Annotations to Clinical Data.

  Hide References to test results

  • Type of test performed
  • Date that the test was performed
  • Time that the test was performed

  Once you add a test result to your note, you can categorize the test result for follow-up activity.For more information, see Including References to Clinical Notes or Test Results.
  NOTE**:** For more information, see Including References to Clinical Notes or Test Results.
• Including a portion of a document from these modules

  Show Description

  You may encounter situations in which you want to reference only selected blocks of text in a clinical note or test result. You can easily copy over any sections, paragraphs, or words from a note or result to include within your note. These fragments are included in the body of your note, identified by a reference to their source clinical note or test result.
  For more information, see Including Text from a Clinical Note or Test Result.
• Including the entire contents of a document from these modules

  Show Description

  In some cases, you may choose to include an entire clinical note or test result in the body of your note. There is a maximum of up to 5 full tests or notes that are allowed to be included within the data section of a written note. However, it is recommended that you use discretion when choosing to include an entire note or result.

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Including References to Clinical Notes or Test Results

When you navigate from within a note template to view either Clinical Notes or Test Results, you have the option of including references to one or more documents from these modules. To include a reference to a clinical note or test result in your note:

1. Navigate to the section of your note template that provides links to the Physician Portal modules, and click either the Clinical Notes or Test Results link. Either the Clinical Notes or Test Results screen displays the complete list of notes or results entered for your selected patient over a defined duration. This duration is determined by the date range filter drop-down in the upper right-hand corner of the portal.
2. Click on one or more check boxes corresponding to the notes or results that you want to reference in your note. Click the Copy to Note button. References to the selected test result is included in your note. You can enter additional comments and annotations after adding references to clinical notes or test results.
   In the case of test results, you can also categorize these results for follow-up action. A drop-down menu displays with each test result added to your note template so that you can assign the result to one of the following categories: Normal, Abnormal, Unremarkable, Pending, Unchanged, or Other (allows you to add another value).

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Including Text from a Clinical Note or Test Result

The procedure for including text of a clinical note or test result is very similar to the procedure for including a reference to an entire note. You can select and add any selected text or test result data that you want to copy using two different methods. To include part of a clinical note or test result in your note:

1. Navigate to the section of your note template that provides links to the Physician Portal modules, and click either the Clinical Notes or Test Results link. Either the Clinical Notes or Test Results screen displays the complete list of notes or results entered for your selected patient over a defined duration. This duration is determined by the date range filter drop-down in the upper right-hand corner of the portal.
2. Select the note or result that has the data that you want to copy to your note. For example, to include a section from a chest x-ray test, use the date and time to locate the test you want from the Test Results list.
3. From the Chest X-ray Detail screen that displays the contents of the test result, use your mouse to select the block of text you want to include in the body of your note, and then click the Add Selected Text button. For example, you might select only the test procedure. The select text displays in the Text Selected for Note box, and the checkbox is checked for the selected test result.
   When a provider adds text to a note, and later adds additional information by selecting Add Selected Text, some of the secondary text may already be present in the note. Rather than duplicating the text or displaying an error message, the new text is appended to the previous text.
   To remove a text selection from the Text Selected for Note box, use your cursor to highlight the unwanted text and click the Remove Selected Text button at the bottom of the Text Selected for Note box. A button is provided that lets you undo the removal of text in case you remove a selection accidentally.
4. If adding from within a note, click the Copy to Note button. If selecting text prior to starting a note (for example, when pre-rounding), then start the note to add the text. The test procedure is included in the body of your note, identified by a reference to the source test result You can enter additional comments and annotations after adding one or more parts of a clinical note or test result.
   In the case of test results, you can also categorize these results for follow-up action. A drop-down menu displays with each test result added to your note template so that you can assign the result to one of the following categories: Normal, Abnormal, Unremarkable, Pending, Unchanged, or Other (allows you to add another value).

To include part of a clinical note or test result in your note using Start and Stop labels:

• From the detail screen that displays the contents of the test result, move your mouse to the area of text to include in the body of your note. The Start and Stop labels of the setting determine the area of text that is highlighted, and an Add to Note button is displayed. Click the button to add the highlighted text to the note.

Show Settings that control this feature

• Admin > Institution > NoteWriter > Set Findings/Impression Labels

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Adding Annotations to Clinical Data

After you copy clinical data from the Physician Portal into your note template, you may discover the need to provide additional notation in your note template to supplement this data. In such cases, you can add annotations to all clinical data that you copy into your note. Use annotations to remind yourself to follow-up on a particular lab test or other test result. Or, annotate clinical data to provide background information on a particular section of a note, so that you can consolidate content from other clinical notes or results and restrict the duplication of content across multiple note instances. All text that you include in your annotations displays in your note only; this text is not added to the original clinical data that you copied over from one or more of the Commure Pro modules. As with all other data added to your note, your annotations are visible only to you while your note remains in draft status. Once you sign your note and it is added to the Clinical Notes list, your annotations are visible to all users in your department, just like the other content in the note. To annotate clinical data copied over from the portal:

1. Navigate to the section of your note template that provides links to the Physician Portal modules, and click one of the links to copy clinical data into your note template. For example, add selected text from one of the notes available through the Clinical Notes module.
2. From the clinical data entry in your note template, click the Annotate button associated with the clinical data for which to add the supplementary note. For example, you might click the Annotate icon associated with a Clinical Notes entry. An empty text field appears under the heading describing the clinical data.
3. Enter your annotation into the empty text field associated with the clinical data that you want to annotate. You may have the option to use Quick Text entries for this field if Quick Text entry is enabled. Once you sign your note or save it in draft form, your annotation displays with its associated clinical data when you print the note. To see how your annotation will look once our note is finalized, you can click Print Preview to see a view of the note in preview mode.

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Deleting Clinical Data from a Note Template

You can delete clinical data from your note as long as the note remains in draft status; once you sign the note, it is finalized. You can delete individual documents of clinical data, or an entire set of documents from a module. To delete a single document containing clinical data:

1. Navigate to the section of your note template that displays the clinical documents.
2. Click the Delete button that displays to the left of the document that you want to delete. The document is deleted from the list.

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To delete all documents from a particular clinical data module

1. Navigate to the section of your note template that displays the clinical documents.
2. Click the Delete icon that displays to the left of the module name. All documents that you have entered for the particular module are deleted.