Documentation SmartTools

This Epic-branded term (Documentation SmartTools) refers to a collection of workflow efficiency tools that can ease documentation and charting in a clinical information system. Although SmartStuff extends beyond documentation (e.g., SmartSets and SmartGroups relating to order-management), many of the documentation SmartTools are readily available to end-users who wish to personalize existing documentation objects, or create their own. Typical documentation SmartTools include:

  • SmartLinks

  • SmartLists

  • SmartPhrases

  • SmartText

  • SmartForms

SmartLinks

This branded term refers to a text-expander 'SmartTool' that allows a few characters ('dot' command or token) to be swapped for dynamic information pulled from the health record. Typing ".lname" followed by a space or return key, for example, will be replaced by the current patient's last name. Within SmartText and SmartPhrases, links can be tokenized (e.g., "@LNAME@") so that the value is replaced each time the text automation is used.

SmartLinks can be nested within SmartText and SmartPhrases.

Identifiers

  • Master File: HHS

  • Tool: SmartLink Search

  • Reporting Workbench Template: SmartLink Master File Search (HHS)

Constraints

  • Embedded link codes cannot exceed 256 characters, including delimiters ("@" at beginning and end).

SmartLists

This branded term refers to a text-expander 'SmartTool' represented by a token embedded in a block of text. When selected, the token expands to present a list of pre-configured options which, on selection, are substituted for the token. One can navigate from token to token and so change a templated block of text into completed narrative.

SmartLists can be nested within SmartText and SmartPhrases.

Identifiers

  • Master File: ELT

  • Tools: SmartList Manager, SmartList (Editor)

Syntax

  • {display name :ID:connection logic:default value(s):show label}

Parameters

  • Display name - This can be overridden after adding a SmartList by replacing the words preceding the first colon.

  • ID - ID of the SmartList that appears to end users. Only change this if you want to point to a different SmartList.

  • Reselectable - determines whether users are able to return to a completed SmartList to change prior selections.

  • Optional - determines whether users are obliged to make a selection before a note can be saved.

  • Connection logic - This is only for multiple select SmartLists. For example, you could override "and" connection logic that is set up in a List with "paragraph" connection logic when used in a particular Text. Other examples:

    • And - "antibiotics, cough suppressants and nasal steroids"

    • Or - "antibiotics, cough suppressants or nasal steroids"

    • Nor - "neither antibiotics nor cough suppressants nor nasal steroids"

    • None - "antibiotics, cough suppressants, nasal steroids"

    • Sentence - "antibiotics cough suppressants nasal steroids"

    • Paragraph - items are returned each on a separate line

  • Default values - In the Text editor, click Override SmartList Defaults. The window that opens shows a tree structure of all SmartLists for this SmartText. Expand the desired list and choose default values. In the Phrase editor, when you insert a List, on the SmartList Lookup window, click the Default? check box next to the values you want selected.

  • Show label - controls whether the SmartList should resolve with a label prepending it. This parameter overrides what is specified in the Include as label field of the corresponding SmartList record. 1 ﴾Yes﴿ means the display name will appear as a "label" after selections are made from that list. 0 ﴾No﴿ means a label will not appear, even if the SmartList record was configured with Include as label selected.

Capabilities

SmartLists have a number of advanced capabilities. It is possible to nest other SmartTools (e.g., SmartText, SmartLinks) within lists and also to embed lists within lists.

Grouped Lists

Embedded Lists

One or more "child" lists are created first. These can then be added as options within a parent list. For example, a parent option in a SmartList for selecting laboratory results to show, could appear as "CBC". Selecting this would cause a child list of options to appear, allowing the user to specify particular tests within a CBC panel (e.g., Hb, Plts) to be displayed.

Limitations

SmartLists are unable to return documentation elements other than text. Things like images or icons or hyperlinks cannot be returned. However, if SmartText is embedded within a SmartLink, that SmartText can contain a wider range of documentation elements.

SmartLists may be used by many other SmartTools and so need to be edited with caution. The SmartText editor includes features for checking dependencies.

Discrete Data

SmartLists can reference a SmartData Element (SDE, HLX master file) to store user SmartList choice values as data (HLV master file), usually where a categorical SDE has its values mapped to the selectable options in the SmartList. The "use discrete data" option must be selected, appropriate SDE(s) must be known or created and option-value mappings must be entered.

SmartPhrases

This branded term refers to a text automation tool with diverse applications in a clinical information system. A SmartPhrase is a text-expander SmartTool that allows a few characters ('dot' command or token) to be swapped for a longer phrase, block of text or templates. Typing ".pt" followed by a space or return key, for example, will be replaced by "patient".

SmartPhrase tools can be used almost anywhere that text is produced in the clinical information system.

Identifiers

  • Master File: HH1

  • Tool: SmartPhrase Manager

SmartText

This branded term refers to text templates that facilitate documentation within a clinical information system. SmartText is an umbrella term for complex automation of text format, structure and content. Often combined with other 'SmartTools', SmartText may include SmartPhrases, SmartLinks, SmartLists, SmartForms and SmartBlocks.

SmartText templates can be used with any templated text but most commonly serve in progress notes, consultation notes and letter templates.

There is a lot of overlap in functionality between SmartPhrases and SmartTexts. Functional differences include the fact that SmartPhrases are usually user-selected whereas SmartText can be configured as the default for a class of documentation (including variants conditional upon the application of rules). However, the most useful distinction might be that, in general, SmartTexts are built and maintained by Analysts while SmartPhrases are primarily the domain of Users. SmartTexts are preferred when the intent is a system-wide documentation standard.

Identifiers

  • Master File: ETX (for SmartText and note templates)

  • Tool: SmartText Editor (SmartTools)

Embedded Comments

Curly braces ({}) can be used to embed instructions or other comments within a documentation text automation (SmartPhrase, SmartText). The embedded instructions can also include hyperlinks and/or internal links (e.g., {F2/Delete: This is important for you to know}).

A new note cannot be signed until all embedded comments have been deleted by the user, which limits the efficiency of this method of providing just-in-time guidance to documentation template users.

A work-around to avoid embedded instructions having to be manually deleted before signing is to take advantage of a "dummy" optional SmartList that includes the instruction link in the label (e.g., "{POC Discharge Summary Instructions:33568}"). These automatically disappear when a note is signed.

SmartForms

This branded term refers to structured-data-capture and text-generation templates that facilitate charting within a clinical information system. These customizable forms can be used to facilitate point-and-click specialty or problem-specific information management, collect data for a study, or extend other text-automation tools.

There are different classes of SmartForms with different features. Physical assessment SmartForms are used on the Physical Exam tab of the NoteWriter to speed accurate recording of patient assessments while storing discrete data. Delivery Summary SmartForms facilitate obstetric documentation. Operative log SmartForms help manage multiple preoperative information management tasks. Finally, NoteWriter SmartForms can be used to streamline standardized documentation needs triggered by, for example, a patient's chief complaint or reason for visit.

SmartForms are distinguished from other SmartTools. They are optimized for:

  • Discrete data - with data selection linked to SmartData that can be subsequently retrieved for review, reporting and rule criteria.

  • Text generation - with the ability to generate flexible prose from discrete data.

  • Scripting - where a profile can be saved or applied to set many data values to states befitting commonly encountered scenarios.

  • Images - allowing for image incorporation, interaction and annotation.

  • User interaction - with interface elements that speed data selection.

Identifiers