Segment Note
Tutorial
The combination of Palmedic and the Segment Note plug-in
provides significant power to the user for virtually
automatic note creation. This tutorial is a means of showing
how simple creation of notes can be by using this
combination.
Creating a patient and entering demographic information
is expained within Palmedic's online
documentation. The final result is shown here:
Patient admission data, problem list, and medications are
entered as is discussed in Palmedic's online documentation.
Example results are shown here (screen shot modified):
The History and Physical is now ready to be created.
Select Segment Note from the New button popup, and wait for
the new segment note to appear. Tap the Title label and
await the segment note list floater (Be sure you have loaded
the segment note templates prior to doing this so that some
ready-made templates are available).
Check the History and Physical template item,
and close the floater so that the H&P template is
entered as a new note.
The history and physical as "segments" appears as a new
note. Tap the "Show Note" button and see how the note
appears at this moment. You will note that several items
have automatically been entered including: chief complaint
from the admissions module, medications, and allergies (if
any have been entered, otherwise NKDA). There are also
several other items waiting to be entered via macros
(demarcated by the symbols "<_" and "_>". There are
other items that still need some work... Close the visible
note by tapping the small close "x" at the bottom right hand
corner of the note, and thus review the "segmented note."
Now tap "History of Present Illness" in order to view that
particular segment.
If you're familiar with "regular" notes within
Palmedic, the individual segment view will be familiar.
Here is where you enter text, pictures, and macros to
create individual segments of your note. Personally, I
much prefer using Transcriptionist and its tie ins with
Palmedic to create my notes. Thus, I tap on the
Transcriptionist icon to the right of the Segment title
in order to open Transcriptionist. If you have a macro
within Transcriptionist named History of Present Illness
(i.e., equal to the Segment title), it will automatically
be opened for you. There is a basic set of Transcriptionist
templates for use with the segment note plug-in
located on our web pages.
Once the note is completed within Transcriptionist, the
program is closed and the note is entered into the HPI
segment. We can now close this particular segment by tapping
on the small "x" at the bottom right of the note module and
see the listed segments once again. Again, tap the "Show
Note" button to see the History of Present Illness now part
of our note.
The H&P proceeds with the Past Medical History. As
you are talking with the patient, tap the New button, and
select Problem. A new Problem
module appears within the edit
view. Tap the description diamond within the module to
access the ICD-9 code list (if you have not downloaded and
loaded the code soups that are found with the billables
plug-in, no problems will appear within this list). As
the patient tells you his medical history, you can search
through and find the problem within this list.
"Diabetes..."
"Hypertension..."
"Congestive Heart Failure..."
Once the patient is finished and you have checked all the
items in the list, close the list using the large "x" button
in the lower right hand corner of the list floater. All the
checked items are entered as problems into the patient's
problem list. You may then mark these as "PMH" within the
Problem module description entry
line if you so desire.
Now, go back to the note we were creating by tapping the
Show button and selecting Notes.
For the sake of example, tap the Past Medical History
segment so we can view what is there at this moment. It says
"PAST MEDICAL HISTORY: <_Problems List_>". The text
"<_" and "_>" demarcate a macro entry that is part of
this template. This particular segment has been set as a
non-"auto macro," thus you must tell the note when to
process the macro. If this had been set as an auto macro
(like the Medications segment that we previously saw had
been automatically entered), the macro would have "run" at
the time the note was created.
[Note: The creation of
templates is discussed in more detail in the documentation
of the segment note.] We can run or re-run a macro
by tapping the macro icon to the right of the segment title
in either this segment edit view, or the segment list view.
Tap the macro icon button now to "run" the macro within Past
Medical History.
The "Problems List" macro item pops up a floater
listing all of the problems within a patient's problem
list. [Note: We could
have just as easily used the macro "PMH" here and
Palmedic would have entered all the problems whose
description was "PMH"]
The list floater allows you to select the items you
wish to include in the text, and delineate the list items
in any manner you wish. Select the three PMH items we
entered earlier and assure the comma is selected as the
delineating character. Check the "and" check box to tell
Palmedic to use an "and" before the last item in the
list. Now close the list floater and the three items
appear within the note, separated by commas and an "and".
The macro can be "re-run" at any time by tapping the
macro icons here or in the segment list.
The same process is undertaken for surgical history,
entering procedures in this patient's Procedure
list modules, and tapping the macro item associated
with "Past Surgical History."
Family History, Social History, and Review of Systems
all have been set up in this template to use
Transcriptionist as an enty tool. The segment note bundle
found within the Transcriptionist
Template Archive contains boiler plates for these
three aspects of the history. In this manner, complete
histories within these three segments can be taken in
very little time.
Next in the segment list is the Vital Signs entry. You
will note that it too is a macro item. It has been
designated as an "auto macro," so you will note if you
look in the note segment itself, the data is absent. That
is because we haven't entered any vital signs data yet!
So let's do that now.
 Tap
the New button and select Test. Next, tap the Title label
diamond within the new Test module
that appears. The test template list floater will then
appear. You will note it is quite similar to the note
template list floater and ICD-9 code list floater that we
have worked with previously.
[Note: Example test
templates are installed with the Palmedic Installer. If the
list is empty when you open it, it would be helpful to
install the templates with the Installer before
proceeding.] Select the test "Vital Signs" within the
list and close the floater. The "Vital Signs" test template
is entered in place of your new test. Entry into and
creation of input field test templates is covered in the
documentation of the Tests module
plug-in.
Once you have entered the set of vital signs data, you
may return to the segment note we've been working on by
selecting Notes from the Show button popup menu. Tap the
macro icon found to the right of the Vital Signs segment
list item to re-"run" the Vital Signs macro. You may then
open the Vital Signs segment to take a look at what
happened. The Vital Signs data we just entered has been
entered into the note!
Entry of Physical Exam is done very easily and completely
via a Transcriptionist template (included in the segment
note bundle on the Transcriptionist
Template Archive). Entry of Assessment and Plan is done
via macros and handwriting recognition. Complete the note
now as you so desire using these powerful methods, and view
it by tapping "Show Note" or by selecting Preview within the
Print Note dialog (select Print from the note module router
envelope found in the top right hand corner of the
module).
To be continued with examples of Progress Notes and
Discharge Summaries that detail even more powerful features
of Segment Notes like automatic loading of segments from
previous notes...
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