Intro to PowerForms Computer-Based Training

1. Presented by the IS Training Department of Children’s Hospital of The King’s Daughters Revised May 2012 Intro to PowerForms Computer-Based Training

2. Course Contents • Ad Hoc Charting • Patient and Form Selection • Working with Forms • Charting PowerForms • PowerForm Browser

3. LESSON 1: Ad Hoc Charting The Ad Hoc Charting Feature allows a user to open any PowerForm the user has access to any time. Essentially, it is a file cabinet of blank PowerForms. PowerForms are forms that are comprised of multiple sections displayed as templates that are customized for CHKDHS. They are used to capture clinical data. When you have successfully logged into PowerChart you can access charting features from several places including the Patient Access List. These options are security based and will not be available without the appropriate security level. 3 Introduction to PowerForms

4. LESSON 1: Ad Hoc Charting You can also access the Ad Hoc Charting features from within the patient’s chart in PowerChart.

5. LESSON 2: PowerForm Selection - Ad Hoc Charting After you have selected your patient, the Ad Hoc Charting window will display. The Ad Hoc charting window contains two panes. The left side displays folders that group similar PowerForms. However, these forms are not used at CHKD and should never be selected. The right side contains the PowerForms grouped under the selected folder.

6. LESSON 2: PowerForm Selection - Ad Hoc Charting After you have identified your patient, the Ad Hoc Charting window will display. PowerForms should NEVER be accessed from this section. This section contains the PowerForms that you have access to for documentation based on your user security.

7. LESSON 2: PowerForms Toolbar The PowerForms toolbar contains the following elements.

8. LESSON 3: PowerForm Layout Form Navigator Form Sections

9. LESSON 3: PowerForm Navigator PowerForm section names in the Navigator with a light blue background are available and have been accessed, but are not currently open. PowerForm section names in the Navigator with a dark blue background are the PowerForm section that is currently open. PowerForm section names in the Navigator with a white background are the PowerForms that are available but have not been accessed. PowerForm section names in the Navigator with gray background are conditional sections that are inaccessible until activated by an answer from another PowerForm field.

10. LESSON 3: Required Fields The required field Icon in the Navigator indicates there is a required PowerForm field within that PowerForm section. Required fields within each PowerForm section are indicated by a bold-yellow background.

11. LESSON 3: Interacting with PowerForm Section Fields You can right-click within PowerForm fields to review options available. Comment: You can add textual comments within various section fields. View Result Details: If there are result details associated with that section field, you can review these results. Clear: You can clear the inputted data for that specific field without clearing the entire PowerForm section. Chart Details: You can add a comment about a specific detail within the selected cell. Clear: You can clear the current grid, without clearing the entire PowerForm section. Clear Cell: You can clear the information in the current cell within the grid, without clearing the entire grid or PowerForm section. Add Row: You can add an additional data row within the selected grid. This option is only available for Ultra Grids. Delete Row: You can delete a data row within the selected grid. This option is only available for Ultra Grids.

12. LESSON 4: iView I&O 2G Tab Some documentation that is entered in PowerForms will flow to the iView I&O 2G section of the patient’s chart. This is the interactive flowsheet section. For example, a Pain Score of 6 has been documented in the Pain Assessment section of the Pediatric Admission History PowerForm below. Notice that the Pain Score is also documented in the iView I&O 2G section.

13. LESSON 4: Results Review Tab In addition, the documentation flows to the Patient Care sub-tab in the Results Review section of the patient’s chart.

14. LESSON 5: Charting Options After accessing the PowerForm and entering your data, you can either sign the PowerForm and chart the data or you can cancel the PowerForm without charting any changes.

15. LESSON 5: Signing PowerForm When the PowerForm is completed and you are ready to chart the PowerForm, select the ‘Sign Form’ icon to save and chart the data. If you are unable to complete the PowerForm, you can sign the entered data and access it later through Form Browser to modify and complete the documentation.

16. LESSON 5: Cancel Charting You can cancel charting the PowerForm without saving by selecting the ‘Cancel’ icon. Select ‘Yes’ on the Cancel Charting prompt to cancel current charting, and return to the previous screen; Task List, Patient List, or Patient’s chart. Select ‘No’ on the Cancel Charting prompt to return to the current PowerForm.

17. LESSON 6: Form Browser Basics Information or results entered during the charting process for the patient are available on the patient’s chart. The charted results can be viewed within the related Flowsheet, and the charted PowerForm is available in the Form Browser tab within the patient’s chart.

18. LESSON 6: Form Browser Basics The Form Browser window displays a directory tree that lists all the charted, in progress, and uncharted PowerForms for the selected patient. • A red icon indicates a required field was not completed. • A blue icon indicates all required fields were completed.

19. LESSON 6: Sorting PowerForms You can sort the PowerForms by Date, Form type, Status, Encounter - Date, or Encounter - Form by selecting the Drop-down menu. NOTE: If the sort criteria of ‘PowerForm’ or ‘Date’ is selected, then the status of the PowerForm (Authenticated, Verified, Modified etc.) also displays.

20. LESSON 6: Changing PowerForm Date Range The PowerForm Brower tab displays a default time range. A user can change the time range for the current session. Right-click the information bar where the time range is displayed and select Search Criteria.

21. LESSON 6: Changing PowerForm Date Range The PowerForm Browser dialog box will open. To view PowerForms within a specific date range, select the Date Range in the View Range group box and enter the From and To dates and times. To view all PowerForms from admission to the current date, select Admission-Current in the View Range group box.

22. LESSON 6: Viewing a Completed PowerForm Completed PowerForms can be viewed in a read-only format. To view a completed PowerForm, right-click on the desired PowerForm and select View from the menu to open the PowerForm. You can also double-click on the form to open it in Form Browser.

23. LESSON 6: Modify a PowerForm To modify the information on a charted PowerForm, right-click on the desired PowerForm and select Modify from the menu to open the PowerForm.

24. LESSON 6: Uncharting a PowerForm Results that were entered in error (charted to wrong patient, for example) can be uncharted. To unchart results that were entered in error right-click the PowerForm occurrence and select ‘Unchart’ to open a comments dialog box . Enter the reason for uncharting the PowerForm in the comment section as EID(Error in Documentation) and save.

25. LESSON 6: Viewing Document History To view a PowerForm’s documentation history, right-click on the PowerForm occurrence and select ‘History’ from the menu. The ‘Action List’ dialog box opens to display the user name and date/time when any action on the PowerForm occurred.

26. End of Lesson Six • End Of Show For additional information related to PowerForms refer to the Clinical Documentation Manual located on Kdnet. To complete the Clinical Documentation Basics Competency, click here.