How Do I Do This?

The Unofficial Answers to some Frequently Asked Questions about Firstnet

Where is the manual?

You can browse or print the minimal introduction by Daniel Wachsstock or the complete manual by Dave Lickerman. You can also contact one of the physician superusers (Tobey Harris, Dave Lickerman, Daniel Wachsstock and Jim Wessley) for help.

What am I going to forget that I should always remember?

Make sure you are charting on the correct patient and are signed in under your name. Look in the upper left hand corner of the window frequently:

Some "orders" need to be put in as two orders (the care sets put them together for you).

• IV fluids need to be ordered as "IV Start" and the specific fluid (e.g. "NS 500ml at 500ml/hr for 1hr")
• Respiratory meds need to be ordered as "Nebulizer" (this is what tells the nurse to page respiratory) and the medication (e.g. "albuterol"). If you want to call respiratory yourself, call extension 7558.
• Consults and PMD calls need to be ordered as "MD Consult (ER Use Only)" (Don't use "Notify MD" or "Call MD" which ends up on the nurse's list rather than the secretary's) with the name of the doctor you want in the Enter Verbatim Order: field. You also have to document the callback in your note (under the Consults section in the Medical Decision Making section). Remember to include the time of the callback! Just click on time== and it will fill it in for you.

Document the hospital course, changes in vitals, whether tolerating po, follow-up exams, etc.

Document pertinent lab and xray results

How do I unassign a doctor who forgot to sign out?

In the Organizer screen (the whiteboard with all the patients listed), double-click on the DR column in the row for the patient you want to sign up for. The Assign Provider dialog will pop up: Select your name from the ED Provider list and click OK.

How do I get results on something the lab QNS'ed (Quantity Not Sufficient)?

If the lab requires a sample to be redrawn, they will call the nurse. However, the doctor needs to reorder it! The nurse should track you down and tell you to reorder it, then you need to go to the Orders tab, right click on the relevant order and select Repeat, then click Orders for Signature then Sign Now.

How do I order IV fluids?

First, remember to order an "IV Start".

Then, order the fluid you want. It will come up with an IV Details pane: Fill in two of the three details and the computer will calculate the third (Bag Volume means total volume to infuse).

So to infuse 1 liter over 30 minutes, set the "Bag Volume" to 1000 ml and the "Infuse Over" to 0.5 hr. To run at 100 ml/hr for a while, set "Rate" to 100 ml/hr and "Infuse Over" to 4 hr or so.

The units must be included with the numbers: ml for Bag Volume, ml/hr for Rate, and hr for Infuse Over. Any other units will give an error.

Don't order fluids to run for more than an hour or two. The order goes over to the nurse with the total volume at the top and the rate and hours to infuse over at the bottom. It's too easy for the total to be read as a bolus volume and the entire order to be given in one hour.

How do I order meds by weight?

Cerner's Dosage Calculator is actually pretty cool; it's nice they got something right!

First, look in the flowsheet to make sure the weight has been entered. If not, get the nurse to enter it. Physicians cannot enter data in the flowsheet. You can enter it by hand in the dosage calculator, but it will not be remembered when you close it.

Order your medication and set the Strength dose to the number you want and the Strength dose unit to mg/kg: If you use the pediatric care sets most of the meds are already in mg/kg.

mg/kg is at the end of the scrolling list of units, not in alphabetical order.

The Dosage Calculator will pop up:

1. Make sure the weight is correct (enter it if you need to) [Item 1].
2. Make sure the dose and units are correct [Item 2].
3. Look at the computer's calculated dose [Item 3].
4. Select a rounding algorithm (automatic rounding works well) or just edit the number yourself, if you want a round number (100 mg) rather than something like 105.75 mg [Item 4].
5. When you do round, the computer tells you the actual mg/kg of the new dose [Right of Item 3].
6. Click Apply Dose in the lower right. If you click Cancel the dose will be left as mg/kg and the nurse will have to calculate it and come complaining to you.

How do I save things so I won't have to type so much next time?

Excellent question! So excellent, that I wrote a whole 'nother FAQ about it.

How do I write the instructions for follow up?

In the Follow Up tab of the Patient Instructions screen, search for the name of the doctor you want the patient to follow up with in the upper left [Item 1]:

Make sure the followup instructions are listed in the lower left [Item 2]. In the example, there are three follow up appointments listed. If the one you want is not there, it was not recorded and will not be printed. This is most relevant to "free text" follow ups, which have an extra step to record them.

Select the phrase you want from the Within list, or pick an exact date in the In list [Item 3]. Add any additional comments in the far right (there is also a drop-down list of common comments). If the doctor you want is not in the database or you want follow up that is not listed (like "Call when the office opens") you will have to "free text" the follow up.

To enter free text for follow up, click the Add Free Text Follow-Up check box [Item 4]. The right side of the window changes: Type in what you want, then click the Add Follow-up button. If you forget to click it, the instructions do not appear in the lower left and all your work is erased.

If the patient is to follow up with a clinic, there is a database of the local ones under Organization: that may save you from having to free text: The Clinic list is empty; don't try it.

To remove a follow up that you included by mistake (or double-entered), right click and select Remove Selected Item:

Do not click Clear Patient. That will erase the name of the patient (not the doctor!) and you will have to exit the window and start over.

Every time you open the Follow Up tab, the program tries to do you a favor by adding an appointment with the patient's primary care provider in 5 to 7 days. This is even if you've already set follow up. This is a bug but you have to look in the lower left box and remove the extra item

How do I use the tamper-proof prescription paper?

For controlled substances (and, after April 2008, for all Medicaid prescriptions) you need to use tamper-proof paper for prescriptions (the kind that says "VOID" all over if it's copied). This is in the ER discharge printer, in the second tray. To use it, write your prescriptions in EZ Script and click at location: This brings up the printer chooser:

Select the Other Output Devices tab and click the plus sign () by "St. Luke's Hospital" (not the words, the plus sign): Click the plus sign by "St. Luke's Hospital Campus" then the words "Emergency Department". In the right-hand pane, select sler02t2 and click OK. This is the tray 2 of the printer.

If you right-click sler02t2, you get an option to Add to Favorites, which should make life easier by putting this printer in the Favorites tab, but I can't get it to work. Let me know if you figure it out.

How do I include things in my note that aren't in the template (like specific procedures)?

PowerNote tries to create a template that includes everything you could ever want, but nothing is perfect. For a short note, just click on Other... in any section and type what you want.

You can also add text to anything in your note by right-clicking and selecting Comment...

If the part of the note you want to add to has a chevron (»): then click the chevron and that part will be expanded, and you may find what you're looking for:

If you want to repeat a line of a note (say, to document on left and right sides or to document on multiple chest xrays or re-examinations, look for a (repeat): Right-click on the (repeat) and select Repeat (More brilliant Firstnet Redundancy. It's not my fault!): Now, there is another set of terms for you to click:

You can add a whole new subsection (called a "sentence") to a section. This is most useful in the Procedure section, which generally starts off blank. Right-click the section header and select Insert Sentence. This brings up a list of possible sentences for that section. Click on one or more and click OK. They will be added to your note.

How do I use PowerNote's cool built-in video game to optimize coding and billing?

About E&M Coding

E&M Services are the way Medicare and other third-party payers refer to what we do for a living: taking care of patients. Checking a chart to see if a procedure was done is easy; it's either documented or not. Histories, exams, and the medical evaluation are harder, since there are five levels, from 1 (minimal) to 5 (comprehensive).

In the past, doctors could just pick the one they thought was appropriate, but the government thought that doctors ended up with too much money. In 1995, the CMS (at that time, HCFA) developed guidelines for E&M Services that included lots of checklists and bullet points to make grading charts easier for non-technical people. The record was divided into three parts: History, Examination, and Medical Decision Making. Each part was graded from 1 to 5 based on how many bullet points it included, and the level of service was the lowest of those three numbers.

The checklist approach was felt to be unfair to specialists (who may examine only one body system but do it more thoroughly) so in 1997 the CMS issued new guidelines. These were still felt to be too arbitrary and not reflective of good medical practice, so the CMS set out to create better guidelines.

In 2002, they gave up. Coders can use either of the old guidelines, whichever codes the highest. Keeping track of these little points is what computers are best at, and Powernote can help.

DQI (Document Quality Index) or TVL (Typical Visit Level) is Cerner's patented algorithm for coding E&M levels. To use it, click on the arrow in the bottom left of the note:

Up pops a pane with a small spreadsheet. The columns are: HP (History of Present Illness), RO (Review of Systems), PF (Past, Family and Social History), and Ex (Physical Examination). The top row is the points that the algorithm assigned in each category, based on what is documented in the note. The total score is the lowest of these, shown as the green number on the bottom. This is the level of service that is justified by your documentation.

Note that the algorithm does not include the most important part, the medical decision making. You should code based on how sick or complicated the patient is, then make sure the documentation is adequate for that level of service.

If your note is based on an RFV (Reason for Visit) it will be written at the top of the TVL pane and if Cerner's database has information about that RFV it will show you the "typical" level of service for that reason and the "Typical" row of the spreadsheet will show how many elements in each category are "usually" clicked. The "Documented" row shows how many elements in your note are actually clicked, and the "Remaining" row shows how many you have left to get up to the Typical service level. The TVL is also displayed in blue on the bottom of the pane.

Click the upper arrow to expand the pane even further: Now you can see exactly which elements in your note are clicked and counted in the algorithm.

So it's a fun game! Just keep clicking in your note until you hit the high score of 5 and you can bill for an extensive E&M every time. Just kidding; if your patient doesn't deserve the higher level, the insurance company will down code you every time. Some insurance companies do that already.

How do I stop the #@**!! autoscrolling?

With your note showing on the screen, select Customize... from the View menu. In the Autoscroll tab, clear the Enable Autoscroll checkbox. The program should remember this from now on.

If you like the autoscroll, play with the settings to your taste. Some suggestions: move the Initial Speed slider all the way to the right so it's not so slow; set the Stop Distance (how far it scrolls) to something larger; set the Start Distance (how far from the bottom you need to click for it to scroll) to something smaller.

How can I make the note more compact so I can see more on a single screen?

This is pretty obscure. The spacing between items is called the "padding" and you change it by changing the "padding font" size. Even though there are no actual letters in the padding, the note uses the font to determine the spacing. The other obscure thing is that some fonts have minimum sizes. So to change the padding:

1. With your note showing on the screen, select Customize... from the View menu. Select the Font tab.
2. In the Category pane, select "Padding Font".
3. Select the Arial font (it's the smallest one) and type (it's not a choice in the dropdown menu) size 2.3 (that's the smallest size the system will give you; anything smaller will go back to 2.3).
4. Click OK

How do I start a new note?

In the patient chart, click on the PowerNote ED tab. If the Open Note dialog box: opens, good. If not, under the Documentation menu, select the Open submenu and the Open... item (it's the only item in that menu. Nothing like a little redundancy to spice up your life).

Make sure the Reason for Visit tab is selected. Look at the Reasons for Visit pane: If the reason(s) you think are appropriate (clear the checkbox for any reason you don't like), click OK. PowerNote will create a reason-and-age-specific note template for you to work on. Don't forget to save frequently!

If the reason for visit you want is not there, search for it by typing the term in the search box at the upper right: then clicking Search by name and double-clicking the reason you want in the Term pane: and click OK as above.

The window is a little small to see some of the list, but you can expand it the same way as a normal window.

How do I copy my PowerNote into a Word document to use as my H&P?

You can't copy text from PowerNote directly into the clipboard to use in another program. However, every time you save or sign the note, it gets transferred to the Docs tab and into Clin Docs in WebPINS. So sign your note when you are done, click the Docs tab and open the little folder on the left that says "Emergency Documentation" and "ED Note-Physician" and double click your note. The text that shows up can now be selected, copied and pasted into Word.

How do I include digital images in the note?

At the end of the Physical Examination section of the note is Notes. Within that is Scribble Notes.... If you click that you get a drawing dialog box: .
You can paste an image into this, then type an appropriate title in the Image Title box on the upper right .

It looks as though you could open an image file or get images from a camera easily with the icons on the top left , but those are only for files and cameras directly on the Citrix server, which you don't have access to.

However, your computer's C: drive is "mapped" to a drive called "C$" on the server, so if you save a picture to the C: drive you can open it in PowerNote

In more detail:

1. Take the picture and save it on your computer according to your camera's documentation.
2. Find the picture file and right-click, and select Edit.
3. This should start the Paint program. Under the Edit menu select Select All then Copy. The image is now on the computer's clipboard.
4. In your note, open the drawing box as above and select Paste New from the Edit menu.
5. Alternatively, don't open the picture in Paint but make sure it's saved to somewhere on your C: drive.
6. In the drawing box in your note, select Open... from the Task menu.
7. In the dropdown folder list at the top of the Open dialog, select the C$ drive and open your picture.
8. Type a title, then click OK.
9. Sometimes it takes a while for the Citrix clipboard to synchronize with the computer clipboard. If Paste New doesn't insert your picture, try copying it again from Paint and pasting again, or paste the image into a new Paint document and try again. I haven't found a consistent pattern for when it does or does not work.

If you want to insert more than one picture, make sure to click the not-bold Scribble Notes... at the end of the Notes section. If you click a bold statement, the program assumes you want to erase it. Select Undo from the Edit menu if you accidentally erased it. If you need to edit the picture, right click it and select Open.

Do not forget about HIPAA privacy and security! Make sure to delete any identifiable images from your camera and computer.