Creating A Documentation Template - EHR Go

Creating a Documentation TemplateFaculty, thank you for taking the time to learn how to build your own documentation templates and notes inthe Neehr Perfect EHR. This Guide also acts as a step-by-step tutorial. Completing this “activity” will help youbetter understand how to create your own template.Creating a documentation template is a 2-step process:1. The template is created2. Neehr Perfect “publishes” the template for your student’s to use as a progress note in the EHRNote: The screen shots in this Guide will vary based on what is being explained.TerminologyBoilerplate: The “work area” for building the contents of a templated note. When documenting in a templatednote,the templated portion is the boilerplate. See page 3 for how the Boilerplate is used when buildingtemplates.Note: Sometimes called “template” or “electronic note”. The note relays valuable information of the patient,their visit, their health or health care need. The note is often the finished product when a provider documentsin a template. In Neehr Perfect, the student and faculty document in notes by going to the Notes tab andchoosing New Note. Notes can be templated or untemplated.Template: Sometimes called a “documentation template.” In the EHR it is a document with instructions, predefined documentation choices, and/or narrative documentation in a format that has not been produced as anote yet. Documentation templates can play an important role in improving the efficiency of data collection,ensuring all relevant elements are collected in a structured format. A template can be in a note.Template Fields: Allow you to document in predefined text edit boxes, combo boxes, buttons, check boxes, orradio buttons. There are thousands of template fields in the EHR. They can be created to fit specific needswhen developing a template.Step-by-step tutorial1. Open any ‘Practice’ chart. Go to the Notes tab Options Create New Shared Template. On the right sideunder Personal Templates ,enter the title of the template you are wanting to create. Personal TemplateProperties – Name: You can name the template whatever you would like at this point. For example,SCHOOL ASSESSMENT or SMITH,MARY TEMPLATE. See the example below.NOTE: When you are ready to publish your template as a note for your students to see, you willneed to contact Neehr Perfect to have your template title added. Email teaching@neehrperfect.com2. You will see the title you just entered now showing in Personal Templates My Templates. Leave theTemplate Type as “Template.” This will be a simple template, not unfolding. Click on Apply. You will becreating the actual documentation template in the Template Boilerplate.1Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016

Tips to creating a template In the EHR, you can use the step-by-step comprehensive Help tool by clicking on the Help menu Index and then typing in “Template.”You are only allowed so many characters across (horizontally) – the maximum is 80 characters. Look atthe ‘Column:’ to know where you are at.There is no bolding, underlining, coloring or italics like in a Word document.o To underline or add a divider, use repeated dashes, equal signs, or asterisks (------ , ,****** ). Look at other templates to see how these symbols are used.Click on Apply frequently to save work. If you click OK or Cancel and have not saved your work it willbe lost and it cannot be recovered.You can copy and paste from another document (such as a Word document) or within the TemplateBoilerplate.In the Tools Menu of the Template Editor you are able to Create and Edit Template Fields.It is proper EHR etiquette to not look at or change other users work in the EHR. In the SharedTemplates folder to the left you are able to see other templates that are being worked on or are“under construction.” Do not edit or work on any template other than your own.2Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016

Highlight yourtemplate.3. Begin creating your template by typing in the Boilerplate area the following information from the screenshot. Use all caps and enter into your template just as it’s shown. Notice as you enter the information howthe ‘Line’ and ‘Column’ numbers change.Tip: Your template must be highlighted in order for you to document in the Template Boilerplate.You are typing in theTemplate Boilerplate.Click on Applyfrequently to savework.3Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016

Template Fields allow you to create text edit boxes and lists of text that can be selected via check boxes, radiobuttons, or combo boxes. These controls can be added to the template. The asterisk (*) denotes a requiredfield and requires the user to complete all required fields before exiting a template. A message will display atthe bottom of the template to the user: ‘* Indicates a Required Field.’ The Template Field Editor provides thefunctionality of creating new template fields. In the screen shot below of a completed template, the TemplateFields are highlighted. As you can see, Template Fields are used for just about everything.4. Enter the following Template Fields. The first one is shown below.a. Place curser where you want the Template Field to go. After PATIENT AGE: enter a ‘space’ and withyour mouse right-click. Click on Insert Template Field.4Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016

5. Type in the letters EBOX. This is an abbreviation of ‘edit box.’ It defaults with the list alphabetically.Highlight and select EBOX03. This means this edit box allows free-text for up to 3 characters. Thinking thatno ones age in years will be above a 3-digit number this is a good choice.Type inSelect6. Once you have highlighted EBOX03, click Preview to see what the template field will look like. You caneven test it by entering text. You may even Preview what text you are testing. Once you are done with thePreview Template Field click OK.5Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016

7. Then choose Insert Field Done.8. Repeat the steps and fill in the Sex and Date of Admission.a. Sex: (space) right-click Insert Template Field type in Male choose MALE/FEMALE that is aButton Insert Field Done.b. Date of Admission: (space) right-click Insert Template Field type in Date choose DATEREQUIRED that reads *Date Insert Field Done.9. See how you are doing so far - but click on Apply first! Place your curser in the Boilerplate Right Click Preview/Print Template. Test the template if you would like. Preview also! When you are done click onCancel to go back to the Boilerplate.10. Continue building the template.a. Marital Status: (space) right-click Insert Template Field type in Marital choose MARITALSTATUS LIST that reads Check Boxes Insert Field Done.b. Click Apply!6Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016

11. For Employment Status and Insurance you will build new template fields to go into your template. You willdo this next.Creating a Template FieldBelow is an example of a template field editor. The top screenshot is from the Neehr Perfect EHR. The secondscreen shot is from the VA EHR. The left side of the screen (‘Template Fields’) shows the many template fieldsthat have been created and saved and are available for users to choose from as they design their owntemplate. At the right is the contents of the template field. As you can see there are different types oftemplate fields and ways to set up the field to act or to look a particular way.Commonly Used Template Fields Checkboxes – multiple selections can be made from a list. The list can be vertical (separate lines) orhorizontal. Radio buttons – only one selection can be made from a list. The list can be vertical (separate lines) orhorizontal. Edit box – select a number to designate Field Length and Text Length. Date – date field. There is also the option for Date and Time. Word Processing - select a number to designate Field Length and number of lines. Text – items in this field can be for display purposes and excluded from note. Number – lists numbers only.The options are difficult to read, this is dueto the computer screen resolution. There isno need to change your view! You canexpand the screen to get a slightly betterview of the options. They are OK, Cancel,Apply and Preview (in that order). In thenext screen shot you will see a more clearview of the Template Field Editor.7Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016

12. Click on the Tools menu and select ‘Edit Template Fields’.13. At the Template Field Editor pop-up (below), click on New and enter the following ‘New Template Field’name.a. ‘Name’: EMPLOY Your initials, a space, then a 2-digit number. For example, EMPLOY MS44. TheEHR will not allow two template fields to have the same exact name. By you using your 2-letterinitials, and a 2-digit number, there is a better chance of not having a duplication among you andyour classmates or other users of the EHR.b. Then click on the ‘Type’ box arrow choose Combo Box. If you get a pop-up that reads “FieldName is not unique”, this means the name you entered already exists in the EHR. Just click ‘OK’and change your 2-digit number to something else.8Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016

Type here.This template field can beused to Search through allof the templates.c. Build the contents of the template field. Enter the Items you see below in the next screenshot (Notemployed, Full-time, etc).d. Click Preview to see what the template field will look like in the template (documentation note)itself. Click on ‘Cancel’ to get out of the Preview.e. Then Click Apply to save your new template field.9Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016

This is Preview!This is Apply!14. Repeat the above steps from #13 to add another template field for the Insurance entry.15. Click on New at the top of the Template Field Editor.16. Use the same naming scheme as you did with EMPLOY, but use the word ‘insurance’ this time, INSURANCEMS44.17. Build the contents of the template field. Enter the Items you see below in the next screenshot (Private,Self-Pay, etc.).a. Click Preview.b. Then click Apply to save your new template field.18. Click OK to leave the Editor.10Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016

Your initials & numbers.This is Preview!This is OK!This is Apply!19. Back at the Template Boilerplate, follow the above steps (#4 - #10) to enter YOUR ‘Employ’ template andYOUR ‘Insurance’ template (the two template fields you just created). Make sure you choose the one withyour initials and number.20. Click Apply.21. Preview your template Close out of the Preview by clicking Cancel.22. Do not close the Template Editor!11Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016

To publish your template for student use23. Do not close the Template Editor!24. Highlight your Personal Template and drag and drop your template into the word Shared Tamplates. It is afolder and your template will be dropped into the folder.25. Click Apply!12Neehr Perfect EHR Quick Guide to Creating a Documentation Template v2Archetype Innovations LLC 2016