NoteSwift for Aprima - Certified eSupport for... · 2013-10-28 · NoteSwift for Aprima 4 About...

NoteSwift for

Aprima

Tips and T ricks to get the Most out of Your EHR

NoteSwift 4989 Peachtree Parkway Peachtree Corners, GA 30092 www.noteswift.com

07/30/2013

1 NoteSwift for Aprima

NoteSwift for Aprima 2

Contents First Things First ............................................................................................................................................ 3

Assumptions .............................................................................................................................................. 3

About This Document: Typographic Weirdness and Helpful Info ............................................................. 4

Download and Installation ............................................................................................................................ 7

Downloading ............................................................................................................................................. 7

Installation................................................................................................................................................. 9

NoteSwift Forms.......................................................................................................................................... 11

Aprima Interface ......................................................................................................................................... 12

Chief Complaint ........................................................................................................................................... 13

History of Present Illness ............................................................................................................................. 14

Other Commands Available in the HPI Form .......................................................................................... 14

Review of Symptoms ................................................................................................................................... 15

Past Medical History ................................................................................................................................... 16

Social History ............................................................................................................................................... 17

Medication History ...................................................................................................................................... 18

Family History .............................................................................................................................................. 19

Allergies ....................................................................................................................................................... 20

Physical Exam .............................................................................................................................................. 21

Diagnosis ..................................................................................................................................................... 23

Prescribe ...................................................................................................................................................... 24

Plan .............................................................................................................................................................. 25


Introduction

First Things First

Please check the following before starting.

1. Do you have Dragon Medical Practice Edition (DMPE) installed?

2. Do you have Aprima installed?

3. Do you have NoteSwift installed? The section entitled “Download and Installation” gives

instructions on installing NoteSwift for Aprima.

If you can answer yes to all three, then continue! If you need to install any of the programs listed

above, do so before proceeding.

Assumptions

This document assumes that you are comfortable using speech recognition and that you are able to

work with your EHR capably with or without speech recognition. If you are not comfortable with either,

seek training before using NoteSwift.


About This Document: Typographic Weirdness and Helpful Info

There are certain typographic conventions in this document which, once you learn them will help you

discern what is typed, clicked, or said in each example and exercise.

NoteSwift commands, words you say to NoteSwift when you want something to happen, are in

bold and initial capitals such as History of Present Illness.

Where you need to pause your voice for a moment in between commands, we put a comma in

the instruction. For example, Exam, neuro, numbness on the right foot. You would pause briefly

where the commas appear.

If the NoteSwift form has a Next button, it allows more than one listed item. Say or click Next to

add each item into your form. When finished, say or click Done to enter all information into the

form.


If you are using a PowerMic hand held microphone, you have the ability to define hotkeys that can enter text and navigate you around the screen. The PowerMic II uses the defaults below. You can find more information on how to set your hotkeys in your PowerMic II and DMPE documentation.

NOTE: In this manual we assume you will dictate Next and Done, or that you will use a predefined hotkey on a microphone or your keyboard to accomplish the Next and Done functions. When we say “press the Next hotkey” in an instruction, this means whatever hotkey you have defined to work best for you.

This is the predefined hotkey to

enter text for the PowerMic II


The Good Doctor icon. Whenever you see this icon, it means we have some important and

helpful information for you from the Good Doctor and founder of NoteSwift, Dr. Chris Russell. These tips

and tricks will help you learn best practices when working with NoteSwift and your EHR.

Here is your first tip from the Good Doctor!

Often, it can be quickest to use the hotkey assigned to the Next button to get through the forms and

templates. The Next hotkey can be assigned through the NoteSwift Options menu, or through the

PowerMic options (see image on previous page) found in Dragon Medical Practice Edition (herein after

referred to as DMPE).


Download and Installation

Downloading

Important: Be sure that you have DMPE already actively running on your system and Aprima ready to be

run when needed before you start the download process.

In order to downloading NoteSwift on your computer please take the following steps:

1) Turn off UAC (User Account Control) settings based on your Operating System.

Windows 7 instructions for turning off UAC settings – Click Windows Start button -> Control Panel ->

User Accounts -> Change User Accounts Settings. Slide the slider down to the bottom to “Never

Notify”.

Windows 8 instructions for turning off UAC settings – Charm pop out window -> Control Panel ->

User Accounts - > Change User Accounts Control Settings. Slide the slider down to the bottom.

2) Install NoteSwift for Aprima on your computer by entering

http://download.noteswift.com/noteswift/aprima/publish.htm into your internet browser and

hitting the enter key. The NoteSwift for Aprima download page will load into your browser.

3) Choose the “Install” button from the NoteSwift for Aprima download web page (see image below).

4) Choose the “Run” button from the pop up window at the bottom of the download page.

http://download.noteswift.com/noteswift/aprima/publish.htm


5) Accept the Microsoft Supplemental License Terms by clicking on the “Accept” button in the dialog

that appears just before the download begins. This dialog may or may not appear depending on your

system settings.

6) Multiple dialogs will appear during the installation process. Finally, you will see the NoteSwift “Open

User” dialog appear. This indicates the download process was successful.


Installation

Installation starts immediately after the download has completed. During installation of NoteSwift you

will be asked to create a user. You need to create a username and select the name and version of the

EHR you are using. Once you have made your selection choose the “Done” button from the “New User”

dialog.

During install, NoteSwift collects data from Aprima to better understand the way you work. This process

can take several minutes (explained in the image below). Do not touch your mouse or keyboard during

this process as this will interrupt the data collection and abort install.


The installation process will ask you to perform the following steps.

1) Start Aprima. If you already have Aprima open, close it and then start it again.

2) In Aprima, start a new empty patient note and click the “CC” tab.

3) The setup will ask you to click the “OK” button on the setup dialog.

4) Click inside the “Note” text box toward the top of the newly created note in Aprima. This will start

the data collection process.

Once the setup process starts collecting data (after clicking the “Notes” edit box) it is important NOT to

touch your mouse or keyboard until the process is finished. The setup process is finished when you see

the “User configuration complete” message. You are now ready to use NoteSwift!


NoteSwift Forms

NoteSwift forms allow you to dictate free text narrative, or, structured data where NoteSwift does the

searching for you from a defined list. In this document we go through each NoteSwift form and show

you how to create the patient note quickly and easily whether you need free text or structured data.

NoteSwift Forms are:

Chief Complaint History of Present Illness

Review Of Systems Past Medical History

Social History Family History

Allergies Current Medications

Physical Exam Diagnoses Prescribe

Plan* Services Ordered Services Provided

* The Plan tab is reached by speaking one of the following commands:

Internal Notes

Visit Notes

Patient Instructions

Exercise

Return Visit


Aprima Interface

The default setting for Aprima is to have all of the panes expanded. This is the way NoteSwift expects

Aprima to be so that it can interact with the EHR. If you are experiencing any problems with recognition

you may want to check that all your panes in Aprima are expanded and not closed.

In order for NoteSwift to interact properly with the Aprima you should always have DMPE, Aprima, and

NoteSwift open at all times.


Chief Complaint

Call up the Chief Complaint form.

Chief Complaint

The NoteSwift Chief Complaint form appears. Dictate the patients’ complaint. For example:

Dizziness

The word “dizziness” will appear in the Chief Complaint form.

Dictate a Note for the Chief Complaint form such as:

For 6 Weeks

The Note form is updated with this information.

If finished, click or say Done. If you would like to dictate additional information, say Next and dictate

another complaint following the steps as noted above.


History of Present Illness

Call up the History of Present Illness form.

HPI

The History of Present Illness form appears. Dictate the patients’ history. For example:

He comes in today due to dizziness. Six weeks ago he awoke with severe spinning vertigo and left ear

tinnitus.

The words you dictated will appear in the HPI form. If there was existing highlighted text already in the

form, new dictation will replace it.

Use your hotkey to click the Done button or, say:

Done

Other Commands Available in the HPI Form

Append moves the cursor to the end of the existing text and adds additional dictation to the end of the previous dictated notes.

Recover brings back the text from your prior HPI dictation. This is useful if the text was left from a previous dictation.


Review of Symptoms

Call up the ROS form:

ROS

Dictate the symptoms into the ROS form. NoteSwift defaults to positive findings, if you would like to dictate a negative, simply say negative before the symptom. In the example below the patient is positive for dizziness and tinnitus.

Say:

Dizziness

Press the Next button or say Next

Tinnitus

In left ear

Once your review of symptoms is complete, say

Done

Or click the Done button


Past Medical History

Bring up the Past Medical History form.

Say

Past Medical

The Past Medical History form appears.

Enter the medical history of the patient. Say:

Hypertension

A list appears. If more than one choice appears choose the item in the list you wish to select and then

click Next if you wish to dictate more history, or Done, if you are finished dictating the history.


Social History

Call up the Social History form, say:

Social History

The Social History form appears. Dictate social history information such as:

Tobacco History (This text will appear in the Item field)

Current Every Day Smoker (This text will appear in the Detail field)

20 Pack Year History (This text will appear in the Note field)

Press the Next hotkey. The text appears in the Aprima window and you can continue dictating social

history information.

Once done with your dictation Click or Say Done.

The Good Doctor Says: Don’t smoke as it is bad for your health!


Medication History

Call up the Medication History, Say:

Med History

Dictate the medications your patient is taking. Try these examples to see how to dictate medications in

this form. (*Say mg as milligrams.) Say or click the Next button after each medication.

Lisinopril 20 mg daily

Aspirin 81 mg daily

Norvasc 5 mg daily

NoteSwift does the lookup for you and puts the dose in the right places. This can be very helpful if a

patient takes several medications.

Click or say Done when you finished entering Medication History information.


Family History

Call up the Family History form:

Family History

Dictate into the family history form, pausing where you see commas, and remembering to say or click

Next after you have finished dictating each individual’s history.

Mother, Hypertension, Alive

Father, Diabetes Mellitus, Deceased

Click or say Done when you are finished with the family history.


Allergies

Call up the Allergies form, Say:

Allergies

Then speak the name of the allergen, for example, Eggs. NoteSwift will search for the allergen in Aprima

and the cursor will jump to the Reaction box.

Dictate a reaction and then press the Next hotkey to enter the allergen into Aprima.

Click or say Done when you are finished entering the allergen.


Physical Exam

Call up the Physical Exam form:

Exam

Dictate into the Physical Exam NoteSwift form. Remember to pause your voice at each comma you see

in the example below:

Extra ocular movements intact

Left nystagmus on left gaze


Click or say Done to enter the Physical Exam information.


Diagnosis

To add a diagnosis to the patient’s chart, call up the Diagnosis form:

Diagnosis

Say your diagnosis, in this example: Pneumonia.

NoteSwift will search for the diagnosis. You can then dictate an assessment narrative associated with

that diagnosis. Press the Next hotkey to enter the diagnosis into the chart.

If the Diagnosis search returns more than one item, NoteSwift will use the first item on the list unless

you click on another item on the list, in which case it will use that item.

Click or say Done when you are finished with Diagnosis.


Prescribe

To prescribe a medication in a patient note, call up the Prescribe form:

Prescribe

Now dictate your prescription medication. For example:

Meclizine, 25 mg QID, quantity 30

NoteSwift enters the medication name and correct dosage and frequency. A list will appear in Aprima

showing the medication found. Click on the correct medication in the list and choose OK.

Another dialog will appear asking for acknowledgement and if you want to continue. Choose “Yes”.

Click or say Done when you are finished with Prescribe.


Plan

Call up the Plan form say:

Internal Notes

Visit Notes

Patient Instructions

Exercise

Return Visit

Dictate each item’s information.

In the case of “Exercise” you can dictate recommended or restricted and then continue to dictate the

exercise note. NoteSwift will automatically choose the proper radio button, either Restricted or

Recommended.

In the case of “Return Visit” you can dictate the length of the visit and NoteSwift will automatically

choose from the Days, Weeks, Months and Years radio buttons.

Internal Notes, Visit Notes, and Patient Instructions all use free form dictation and do not require any

additional steps


Click or say Done when you are finished with Plan notes.

NoteSwift for Aprima - Certified eSupport for... · 2013-10-28 · NoteSwift for Aprima 4 About...

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