Obstetrician and gynecology specialist Dr. Joelle Dennie has taken her use of the electronic health record (EHR) to the next level. She recently discovered tools in the Cerner PowerChart program that automate and streamline the way she handles clinical documentation.
“One thing that I discovered is you can make step-by-step templates,” says Dennie. “They’re similar to what is already there, but I’ve made my own. When the procedure is repetitive it’s easy to make a template.”
“I’ve made templates for some of my gynecological surgeries, such as abdominal laparoscopic hysterectomy and hysteroscopies. For caesarean sections, the steps are always the same, so I made a template for that. It puts in the date, your name already, every single little step and then all I have to add are the things that might change, which might be three or four items. It’s quite impressive, really.”
Automated documentation done in two minutes
To demonstrate, Dr Dennie said “Create C-Section” into the Dragon mic – and boxes of text appeared in quick succession as the program started typing in the details on its own. It took about 10 seconds for the template to fully load and fill out the bulk of the documentation. She manually added the sex of the baby, the cord clamping, estimated blood loss and some other details. In less than two minutes, Dr. Dennie signed and submitted the completed documentation.
“Even if I were to dictate the usual way through the phone I’d have to dictate through all of those. This way, I can see it, I can change things and then it’s gone and done. I don’t have to go back and sign it electronically within 72 hours because I’ve already looked at it.
The speed at which notes become part of the patient record is an important upgrade that Dr. Dennie appreciates. “I had a situation last Friday when I was in our high-risk OB clinic. A physician called me for a phone consultation. I spoke with her, we made a plan, and I dictated a free-text phone consultation. She texted me an hour later and said “I have your notes already in my EMR”.
Rhonda Gustar, Continuing Education Coordinator at Provider Education and Experience (ProEx) tips her hat to Dr. Dennie’s effective use of PowerChart tools.
“Dr. Dennie is without a doubt a power user, but there are excellent tools to get physicians started.” Gustar recommends two videos on the Cerner wiki: “Creating Custom Autotext” and “Using Dragon Step by Step Commands”. She also reminds medical and clinical staff that eCoach is always available in the EHR to guide you through EHR procedures.