Documentation
Documentation – Modify & In Error
If a mistake is made in Documentation there are two options to change it;
Modify – use this option to strike out words and add an addendum within a note
In Error – use this option to cancel a whole…
Clinical Notes - Uploading a PDF/Scanned Document or Video/Audio file
Uploading a PDF to PowerChart
Note - Before uploading a PDF/scanned document on a patient's chart, ensure you choose the appropriate encounter that matches your Facility, Location, Medical Service…
Documentation - Customising Note Types and Templates
Setting a Default Note Type
It is possible to default the Note Type so it is automatically selected for your account each time you login, and add documentation for progress notes.
Add a New Note in…
Document Launcher - Set Up (Paediatric/Nursing View)
The Document Launcher widget in Paediatric/Nursing View can be customised based on profession or team, providing quick access in one click to commonly used documentation and forms e.g.to write your…
Mental Health - Note Types, Management Plans & Autotexts
Select +Add on the Documentation tab from the navigator menu
Select the applicable Mental Health (MH) Note Type
Select Progress Note (Free Text) from templates then press OKOR
An…
AutoText List (department specific)
Open a free text documentation (see Add Documentation QuickStart)
Type in '.' (full stop) then then the abbreviation of the autotext template you wish to use (note: the list will filter as you type…
Anaesthesia - Creating Pre-Anaesthesia Evaluation Macros
You can pre-fill the Pre-Anaesthesia Evaluation and create Macros (templates) to be used in the future. This can be done for any Major Heading; Summary, Medical History, etc. OR any sub-heading.…
Anaesthesia - Using Existing Pre-Anaesthesia Evaluations as Templates
For patients who have frequent anaesthesia, it is possible to copy one of the patient's previously completed Pre-Anaesthesia Evaluations, modify it and sign/submit.
Open the patient’s chart
Click…
Documentation - ED Nursing
Choosing the Template
Click on the + Add on Documentation.
Select ED Nursing Progress Note.
Select Note Template:
Nursing ISBAR or
Progress Note (Free Text).
Note: One Nursing…
Documentation - Add Images to PowerNotes
In the Documentation tab, select the arrow next to the +Add button, and select PowerNote.
Choose your note Type.
Click the Catalog tab and select Inpatient from the Catalog drop down.
Click…
Documentation - Students (All Clinicians)
Creating a Student Document
On the Documentation tab, click +Add.
The Note Type automatically defaults to the right note based on your position.
Select the appropriate student note for your…
Nursing Progress Note
Click +Add next to Documentation.
Select Nursing Progress Note.
Select Progress Note (Free Text) from Note Templates.
Click OK
Click in the text field and enter your information.
Enter a…
Documentation - Nursing Discharge Instructions
Documentation of Nursing Discharge Instructions
From the Documentation tab, click +Add.
Select the note type Nursing Discharge Instructions.
Double click on the template Nursing Discharge…
Documentation - Creating AutoText Templates
Auto Text can be created in both Documentation and Clinical Notes. Once created, an Auto Text will be available in both Documentation and Clinical Notes.
Navigate to either Documentation or…