Acute Visit Tips

I'm finding that it's easier to do acute visits in Greenway without using a template. I made an acute visit template (you can find it under my username), but the HPI gets me bogged down and steers me away from getting right to the heart of the matter.
So here's what I do:
Click on CREATE NOTE, and then on the PROGRESS NOTE option from the drop-down list, but DO NOT CHOOSE A TEMPLATE!
CC: Click on the WIZARD icon (the magic wand with sparkles in the upper right hand corner of the toolbar) and type in the chief complaint. I also like to type in who is bringing the patient "Here with Mom" and maybe allergies and meds "NKDA; taking tylenol" so they show up prominently in the note.
HPI: To do this without a template, just click on SKETCH PAD in the tool bar. This will open a blank sheet of notebook paper to type or write out your HPI. I like doing it this way, because I can follow the way the patient/parent tells me the story.
PFSH: you do this the same way you normally do. We still don't have this very well fleshed out in most of our charts, but that's a topic for another day :)
ROS: I click on the category that I want to open ("constitutional", for example) and then click on the "C" box. This will open a table with several symptoms in gray. I have organized these in my Review of Systems Admin (under the "Chart" heading on the upper toolbar) to have the categories I want. I prefer to have everything unchecked, so I can go through and hit just the symptoms I want by clicking once for a negative, twice for a positive, or a third time to turn that item off again. I will typically hit four or five systems, but just in a way that makes sense and doesn't clutter the note or take too much time. For the system that is the main focus of the HPI, I click on the "H" box to indicate "see HPI".
VITALS: should have been entered by the MA. If they weren't, click on the WIZARD at the upper right of the toolbar. A new window opens, then you click on ADD NEW VITALS at the upper right. Enter in any values you want to (remember all values are in English, not metric), then click on the ADD VITALS box at center bottom. Then click on the X in the upper right hand corner to close the window.
PE: If your exam is very short and focused, just click on SKETCH PAD and type or write your exam. If it is a more thorough exam, click on the WIZARD again in the upper right hand corner and choose the categories you want to include, or better yet, if you have saved EXAM TYPES you can just click on the TYPE icon just to the left of the Sketch Pad, and a drop down menu will let you choose from your preset exam types. I would strongly recommend putting in some Exam types for yourself, since the exam seems to be the part that bogs you down the quickest. I'll cover how to do that in another post. If I need to change an exam element from my presets, it's usually easiest just to click on the category an go to text view, then click at the end of the sentence to get a cursor. From there I usually backspace to delete the unwanted text and just type in what I want to say without jumping through the hoops of the presets.
IN-OFFICE PROCEDURES: If you do Rapid Streps, UA's or other office procedures that will need a result entered in during the visit, you can click on the WIZARD and choose from the options, or just click on the SKETCH PAD and free text in the result.
ASSESSMENT: Click on WIZARD and add a diagnosis from the search box. This can be a little tricky. The easiest way is to choose a diagnosis from the Wasatch superbill by clicking on the down arrow in the CATEGORY box and selecting *WASATCH. The ICD-9 NAME box then automatically opens and you can scroll down until you find the diagnosis you want, then click on it and click on OK. Other categories that have been helpful to me are A-COMMON PROBLEMS or rarely, the subspecialty categories (usually too detailed and just don't seem to have what I want). My other trick is to click on SEARCH and then click on CODE instead of DESCRIPTION. You can then open a Google search on the internet and type in the diagnosis and the words "ICD-9"; for example, "inguinal hernia ICD-9". You can usually find one or more sites that will give you the ICD-9 code. You then type in the code number back in the Greenway search box and click SEARCH and it should give you the ICD-9 name on the left hand side. You can change the "LOCAL NAME" if you need to to get more specific, then click OK and it will add the diagnosis to your note.
You can also click the little pencil and paper icon to the right of each diagnosis you enter to add a text box explaining your diagnosis or giving a differential, for example. Clicking on the far right icon will add that diagnosis to the patient's problem list.
PLAN: Again, you can either click on the SKETCH PAD and free text it, or you can click on the WIZARD to prescribe meds, order labs or consults, add instructions and set up disposition.

Don't forget to save and hold periodically as you go along.
These instructions take about three times as long to read as it will actually take you to do the note!

One last trick: I have prepared a template that just has common diagnoses and plans specific to those diagnoses. You will find it if you click SELECT TEMPLATE and change the USER to Kevin Lash. Then click on DIAGNOSES AND PLANS FOR MERGE. This will populate a list of common diagnoses for you, whether you have been working in another template or just going from the wizards. Check the boxes that are appropriate, and when you go to plan you should have the logical (at least in my mind-- a little scary, I admit) labs, medicines, and discharge instructions for that diagnosis. You have to scroll down past a list of all the labs first, but then you should get to the specific stuff. This template will layer over well checks or acute visits and should save you some time.
In another post, we'll talk about how to import this template into your User so you can begin to customize your own instructions.

Be brave and give it a try!