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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...

©1997-98 JRAd consulting, Inc. all rights reserved
last updated8/1/98
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