WELFORD CHART NOTES
NEWSLETTER
Volume 21, No. 5 November, 2002
copyright 2002, Welford Medical Computing, Inc. All rights reserved
USING COMMENTS (User's Manual, pgs. 722-723)
Comments are additional statements that you can attach to many items in the program, including Appointments, Allergies, Diagnoses, Lab Book results, Medications, Name Editor demographics, Prescription Log entries, Orders, and Referrals. Although Comments have been in the program for a long time, version 4.2 adds some new capabilities:
1. When inside the Writer, if you edit an Allergy, Medication, or Diagnosis Comment, you can immediately paste it into the Writer by pressing the Playback button.
2. When in the Writer, you can include the Comments about Allergies, Medications, Diagnoses, or Lab Book results by appending _COMMENT to the name of the @function. For example, @Allergies_Comment reports a list of the patient's allergies along with any Comments about each Allergy. @AllBUN_Comment reports all of the patient's previous BUN results, along with their associated Comments; @LastBUN_Comment reports the most recent BUN result, along with any associated Comment.
3. Lab Book Importer test Comments are now stored in the Lab Book as a Comment to the associated test, rather than as a separate Test.
4. Comments on Allergies, Diagnoses, Lab Book, and Medications can now be of unlimited length, instead of being restricted to 255 characters in length.
There are many uses for Comments. For example, you can give a more detailed discussion of the evidence for a medication allergy. You can record who put a patient on a medication when it was someone outside your practice, why a dose was changed, or what the indication is for the medication. You can indicate more detailed information about a patient's diagnosis or problem, such as how and when it was worked up, what stage it is in, etc. You can remind yourself what significance a lab result had for you, where it was performed, or what you told the patient about the test and when.
Let's see some of these features in action:
1. Press Write\Medications.
2. Enter a patient name, such as KELLY ERICKSON.
3. Press Add.
4. For Drug, enter AMITRIPTYLINE. For Instruction, enter "25 mg po tid". Leave Date start as today and leave Date end blank.
5. Press the Comment button. Press Cancel when asked if you want to print a Brochure.
6. For the Comment, type in "Kelly was placed on this by Dr. Jones to treat diabetic neuropathy."
7. Note that if you were to press your right mouse button inside this window, a menu appears. Had you copied some text previous to this point to the Windows Clipboard, you could paste it in here as a Comment by pressing Paste.
8. Press Ok to store the comment, then Ok to store the medication.
9. Note that the Medication Editor now lists amitriptyline, with a vertical bar in the "C" column at the right hand side to indicate that there is a Comment associated with this medication. You can view and edit this comment by pressing Utility\Comment when this medication is highlighted on the list.
10. Now, enter Kelly's Writer by pressing Write\New Note\Note, accepting her name and today's date.
11 Inside the Writer, type "@Medications_Comment". Note that the Comment is included after the name of the medication.
CHART SUMMARIES (User's Manual, pgs. 719-722) Another very useful new feature in version 4.2 is the Chart Summary. A Chart Summary lets you see a wealth of information about a patient with a single mouse click. Remember that you can create more than one kind of Chart Summary for different purposes or different kinds of patients, containing different information. For example, you might have special Chart Summaries for office, hospital, and nursing home patients. You might design a special diabetic chart summary for your diabetic patients, that includes recent glycohemoglobin and urine microalbumin levels.To create a Chart Summary, all you really have to do is create a new Template and assign its Type of Note as Chart Summary. Design the Template to include whatever information you would find useful to have in your Chart Summary, then store the Template. If you want one-click access to your Chart Summaries, put a Chart Summary button on your Toolbar. (Otherwise, just click View\Chart Summary and enter the name of the patient to see that patient's Chart Summary).
Let's create a simple Chart Summary:
1. Press Libraries\Templates\Add.
2. For Template Name, type in a name that reminds you what the Chart Summary is for. If you only plan to have one kind of Chart Summary, you might name it "Main Chart Summary".
4. For Type of Note, make sure you pick Chart Summary.
5. You don't really need to assign a Topic, although you might want to get fancy and add one, which would allow you to call this Chart Summary by typing the topic as the Chief Complaint in a note.
6. Press Ok to edit your Chart Summary.
7. Here is where you get creative. Put in any titles and topics you wish. For example, you might include @History to see the Past History, Family History, Social History, Medications, and Allergies. You might use other Expanders, such as @AdvanceDirectives if you have created an Advance Directives Expander. You can look up recent test results, such as @LastMammogram, or show all test results for the past 6 months using @LabSince6Months, or all lab since the last visit using @LabSinceLastVisit. You can show the last time patients received immunizations using @LastMedication @functions, like @LastPneumovax. Use fonts, boldface, and whitespace to make your final Chart Summary more readable.
8. Press <F10> to store your Chart Summary.
9. Now, press View\Chart Summary. Type in the name of the patient whose Chart Summary you wish to view, and select the Chart Summary you just edited. (If you have created only one relevant Template of Type of Note = Chart Summary, then that Template is used automatically. However, if you have created more than one Chart Summary Template for patients of this age and sex, then a list of all relevant Chart Summary Templates is shown first; select the one you wish to see).
10. Note that you can easily print the Chart Summary on your printer by pressing the Print button; and from inside the Writer, you can press the Playback button to paste the Chart Summary into your note.
SEND US YOUR TIPS
If you have tips, shortcuts, questions, or suggestions for future newsletter topics, please send them to us at:Welford Medical Computing, Inc.
3779 Hermitage Trail
Rockford, IL 61114
or
MEDCOM Information Systems, Inc.
2117 Stonington Avenue
Hoffman Estates, IL 60195
http://medcom@emirj.com