Help with latest echart

The latest version of echart presents a dramatic change in the way we work with notes written for each encounter. The changes are meant to safeguard the authenticity of each notes as written by the original author (or "editor") and makes it possible to track changes when more than one editor is involved. Here is a quicklist of suggestions and concepts to help you work with this latest tool:

(1) Set your preference to display previous encounter notes

• go to preference tab (Pref)
• click "Set Stale Date for Case Management Notes"
• if you have never put anything in then the default is to only show notes from the last 30 days; you can get the default value by clicking the "clear" button; or you can select from the drop down a value, e.g.  6 for 6 months of notes.  If you select ALL the system will open all previous notes. If you have a "thick chart" it may take some time! My preference is 12 months.
  
• all the rest of the notes outside of your preferred duration will be "collapsed" and require you to click the "Downward pointing triangle" on the right hand side to open it

(2) Opening a chart and entering a new note

• in most situation the chart opens with a number of open notes as determined by (1) above, a new note window is opened at the bottom with the date and reason of encounter (transferred from your appointment) already in the edit window and you are ready to type in your new note
• if you have a previously unsaved (but saved by the autosave feature), or saved note but not yet signed; instead of opening up a new window, you will be taken back to the unsaved/unsigned note - in order for you to finish the note and legally save and sign the note. There is, however, a time window, by which the system will take you back to the unsigned note. Beyond that time window, the note will simply remain unsigned but the system still saved the information regarding the editor and the date and time of that note.

(3) Difference between saving and signing a note

• the reason for signing a note (as opposed to just saving it) is that the system will produce a digital signature for this note. The digital signature is a mathematically calculated value (also known as a signature key) based on the text in the note. This signature key is stored away somewhere protected. This process renders the original document unalterable. When you or someone else make changes to the original signed document, a "revision" is produced which in itself is also a legal document requiring a separate signature.

(4) How to view/edit a signed note

• to view a signed note you can scroll though the note if it is already opened making sure you don't click on any part of that window. If the note is collapsed then click the "Downward pointing triangle" on the right hand side to open it.
• if you want to edit a signed note, you can simply click anywhere in the window of that note (including a collapsed note). The note will be expanded into a Edit window ready for you to make changes. That's why you will see a few blank lines at the bottom of the note. These are not real lines. It is just additional space for you to write on the note. Remember to sign and save your contribution to the previously signed note.
• you can view all the revisions of a signed note by clicking the number to the right of "rev" at the right hand bottom of the Edit window.
  
• only the latest signed note can be edited. If you find notes that are in the previous revisions but missing in the current note, you have to copy and paste into the note while in the Edit window.
• *** a common problem occurs when a user unintentionally clicks a signed note to view it. The note opens up in an Edit window. The user then accidentally clicks a space or return. The document then becomes an unsigned document. Every time the chart is opened by the same user he/she is then taken to that window unaware of what has happened previously. A simple way to get out of this is to sign it again.
  

(5) How to view/edit an unsigned note

• when you click on an unsigned note by another editor, you will receive a warning. Currently you cannot over ride and make changes to an unsigned note from someone else. Future release is planned for you to override an unsigned note - after the system has saved the information of the previous editor and time stamp and clearly indicated in the saved document that it was unsigned by the original editor. You are in fact writing a revision of the previously unsigned document.
  
• *** this is a little problematic because not uncommonly a team assistant or student may have written a short note as part of the visit, e.g. BP value. He/she must sign and save the note before you can continue writing into the same note as part of the same visit. Your note will produce a second revision to the original note initiated by your student. Medical legally this is the right thing to do (as unpopular as it is) because the team assistant or student has made the clinical observation and has written the note.

(6) Autosave - how does it work

• when a user opens a chart, the system opens a temporary record (R1) for the Edit window and an autosave record (R2) for that particular patient and user
• the system does an autosave periodically if the note has been changed (if R1 NE R2). The current clock is set at 30 seconds. So it is true that if you type something within that 30 second window and hit F5 (to refresh the browser window) the information will be lost but the previously autosaved record should still be there.
• when you click the "X" of the browser window to exit, the autosave will still save the latest information

(7) Where is my old chart

• if you have migrated from the old chart then you will find it labeled as LAST CHART as the header. Since this note includes all previous visits as if a single document, the editor of this note is the last person who saved it and the time stamp is the very last visit included.
  
• all previous split charts will be labeled as SPLIT CHART as the header. Since each of these split charts include all previous visits prior to the chart being splitted and combined as a single document, the editor of this note is the last person who splitted the chart and the time stamp is the date and time when the split occurs.

(8) What about printing

• you can print all the encounter notes by clicking the printer icon on the right hand bottom of the echart screen (default will be "all"), then click "Print"
• if you want to print notes between 2 time periods, you can click the printer icon on the right hand bottom of the echart screen, enter the 2 dates in the respective fields then click "Print"
• if you want to print any selected notes, you have to click the very tiny printer icon on the right upper corner of each encounter box, followed by the larger printer icon on the right hand bottom of the echart screen (default will be automatically set as "Selected" ) then click "Print"
• ***remember the old chart and split chart are single documents so there is no real easy way to print portions of these notes. What can be is to copy and paste the portion of notes you want to print into a text editor then print it from there
• you can include the CPP and current prescriptions (Rx) by clicking the two little icons (underneath the "Search" button before clicking the large Printer icon
• for the really sophisticated user, you can use the filter (icon is next to the cpp icon) to print notes based on individual editor(s) or role(s) - i.e. all doctors notes
  

(9) CPP (Cumulative Patient Profile)

Well this is still a work in progress. But essentially this is what we are trying to do:

• each item within each box is a legal document just the same as an encounter note, except that we do not yet do digital signature. Each save version of the item will contain the editor and time stamp. When migrating from the old chart, the entire box is assumed to be a single item.
  
• the "Other Meds" box has been moved to the right hand column because it makes sense to have it with the "Allergies" and "Prescriptions". This is a place where you would normally put a list of drugs prescribed by someone else and over-the-counter medications and supplements.
• the naming of these boxes and up in the air. We thought about allowing user in a particular clinic to rename these but it would create chaos when moving record from one system to the next. So currently we leave it as the 5 boxes as before with plans to allow individual sites to add other boxes in the future
• other work pending include coding each item in each box. This is usually required by many provincial conformance testing

More to come...