PART
2: The Doctor's Part of the Note
(Updates:
3/28/2002; 3/31/2002; 4/8/2002, 4/10/2002; 4/16/2002) Please send suggestions/corrections/comments
to Webmaster
- Assume:
- On your computer's
screen, there appears a completed "Top of Note". (you may want
to complete the parts about PCP, Referring MD, ...)
- The file has been
"saved" in "today's directory" (for example: in the
directory named "2002-05-03"
- If it has NOT
been saved, then SAVE it.
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- FILL
in the Doctor's Part
- Fill
in the Doctor's Part of the Clinic Note: HOW?
- EITHER
- Just start
typing
- -OR-
Bring in an "MD-template". ( see below)
- When
the note is complete, see below
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...by
inserting an "MD-TEMPLATE":
- Be sure the
note has been SAVED in TODAY'S
folder - using an appropriate FILENAME.
- Leave the current
note-in-progress ACTIVE/OPEN. Do not MINIMIZE
it. Do not CLOSE it.
- OPEN
the MD-TEMPLATE
of your choice.
- How?
- In Word's
MENU-BAR, click File
> Open, then "navigate" to the "_MD-TEMPLATES"
folder.
- Click (or
double-click?) a particular MD-template to "open"
it.
- Once you have chosen
a particular MD-TEMPLATE --
SELECT -- COPY -- PASTE ==> [CONTROL]
A -- [CONTROL]
C -- [CONTROL]
V
- SELECT
(highlight)
- [CONTROL]
A
-- to "select"
(highlight) ALL of the MD-template
(-OR-
"select" just that part of the template that you want to put
into the note-in-progress)
- COPY
the MD-TEMPLATE.
- [CONTROL]
C --
to Copy
the "selection" (the part that is highlighted)
- PASTE
the "selection" into the Note-in-Progress
-
- Get the note-in-progress onto your screen:
- In the MENU-BAR
of Microsoft WORD, click Window.
- At the bottom
of the choices, you will see a list of "windows" that are
"open".
A checkmark indicates which document is the "current document"
- To make the
note-in-progress become "current",
click the name of your clinic-note.
- In the note-in-progress,
place your CURSOR where you want to insert
("paste") the "selection"
that you "copied".
- [CONTROL]
V
-- to PASTE
the stuff that you've just Copied
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- COMPLETE
THE NOTE-IN-PROGRESS
- Example:
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- WHEN
THE NOTE IS COMPLETE -- SAVE , PRINT x?
- When the note
is complete, SAVE it, then PRINT IT. (Suggestion:
save OFTEN! and PRINT SEVERAL (see below)
- Stick a "Patient
Label" to all pages of the official Medical Records.
- LEAVE the completed
note IN TODAY'S DIRECTORY -- until notified otherwise-- in order for the
note to be archived.(see below)
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- AFTER
THE NOTE IS COMPLETE - :
- Optional - you may print
extra copies for yourself, for the coding clerk, for the referring doctor,
....
- CLOSE
THE MICROSOFT WORD PROGRAM when you are finished
-- don't leave a FINISHED note on the screen. The nurse will know she/he
can enter info about a new patient.
- Optional - you may copy
the file to a floppy disc, or to any part of any server to which you have access from your office computer.
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-
E-MAIL FROM YOUR OFFICE COMPUTER (Windows 2000, Outlook 2000, Word 2000)
(4-16-2002)
- Please read "AFTER THE NOTE IS COMPLETE" above
- You or your secretary may e-mail
a copy of the note from 7.104 JSA
-- here are several ways. Please e-mail suggestions/corrections to the Webmaster. It is much easier to e-mail from your OFFICE computer, which HAS been configured with your Outlook "profile". It is tricky to e-mail from the clinic -- the clinic computers have NOT been "configured" with everyone's "Outlook profile".
- Use OUTLOOK in the usual way - send the clinic note as an ATTACHMENT (NOT cut-and-paste)
- -OR- Open WORD 2000, then open the file (or your COPY of the file).
- NO: In MENU-BAR, File > SendTo
> Mail Recipient. The Clinical Note will be received in HTML (Web) format.
- OK: In MENU-BAR, File > SendTo
> Mail Recipient (As Attachment) The Clinical Note will be received in .DOC (Word) format.
- -OR- On your computer, select a copy of the Clinic Note.
RIGHT-CLICK
> Send To > Mail Recipient > ....
This WILL be sent as a Word .DOC file.
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- ABOUT
MD-TEMPLATES
- The physician
may add a template to the _MD-TEMPLATES folder any time. Be sure to NAME
it appropriately.
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- ABOUT
PRINTING AND PRINTERS
- The network printer
in the Chart Room is (or is supposed to be!) configured as a "backup"
printer for every exam room comuter. You may want to learn how to tell
Microsoft WORD which printer your output will go to.
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- ABOUT
ARCHIVING
- We hope that ClinWeb
will help us to archive the notes. In the meantime, we are trying to develop
procedures to do this either automatically or by hand. We may have to ask you to place a copy of a completed clin-note in a special FOLDER named
"OK-to-archive".(4-16-2002)
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