Sample NationNotes Form

Part 1, Sample NationNotes LBV Form

About This Document

This document is a supplement to the OpenEMR wiki page, Nation Notes. It expands on the original content with the addition of screenshots and more detailed explanation of some materials. NN is fairly complex; these instructions should teach sufficient skills that a person familiar with clinical processes and the basic functions of OpenEMR can produce a useful NN LBV of their own design. For further assistance in the deeper aspects of NationNotes, such as database structures and interface coding, consult the OpenEMR forum and other wiki documentation.

Screenshots in this document were taken from a stock instance of OpenEMR v-4.1.1 installed on a Lenovo Thinkpad netbook running Linux Mint 13 (64 bit), equivalent to Ubuntu 12.04 Precise Pangolin. The data in the displays comes from random simulated patient data generated by the excellent PrintaPatient package at OpenEMR Tools

NationNotes is minutely detailed. The materials covering its use have been divided into three wiki pages:

Part 1, this page, Sample NationNotes Form

Part 2, Building the Sample NationNotes Form

Part 3, Using the Sample NationNotes Form

About Nation Notes

NationNotes is one of the data types that can be assigned a LBV form data field. That data type augments the field in two ways: 1) it provides rich text content similar to a MS WordPad document, and 2) it organizes the data to allow granular control of the contents of a note. However, the added flexibility and complexity means that the use of NationNotes is significantly more intricate than using a regular LBV form data field.

The WYSIWYG editor that manages the NN fields provides such capabilities as embedded graphics, rudimentary tables, special characters, and formatted and styled text. Programmable buttons and links insert pre- composed text into a Nation Note field, and the field contents may be printed directly from the NN editor. Additionally, the editor organizes each NN field's data into a structure which makes for rapid generation of complex clinical notes.

NationNote's Data Organization

The WYSIWYG editor compartmentalizes its data into three layers, which can be visualized as a three level 'outline':

I. Context1

A. Category

1. Component

II. Context2

A. Category

1. Component

2. Component

3. Component

B. Category

1. Component

2. Component

III. Context3

A. Category

1. Component

Any number of Contexts may be created, each having any number of Categories, which may have any number of Components.

The top level is called the "Context". When building the LBV form with the Edit List function, a NN field is assigned its Context from the List dropdown list. The List dropdown contains all Contexts that have been created for any Nation Note in that instance of OpenEMR, and any Context may be assigned to any NN field. The Context of the NN field might be thought of as the nature of the information recorded by the NN field. A NN field may have assigned to it only one context at a time.

In a SOAP note, for example, Subjective, Objective, Assessment and Plan would be reasonable Contexts to assign each of the four NN fields that would probably make up that note. As it happens, those Contexts are provided by default in the List dropdown. However, the SOAP note format is only one way to document clinical activities. The nature of the data to be recorded by the NN field should determine the name of the Context, and custom Context names can be created as needed.

The midlevel of the data structure is called the "Category" of the information inside that Context. A Category is a subdivision of the Context it belongs to; each Category contains a custom collection of user- defined text which may be inserted into the note.

The term, 'Template' refers to all of the contents of a Category. Templates may be shared between users of an OpenEMR installation, which makes office- wide uniformity of documentation possible. This will be demonstrated in Part 3.

The lowest level of the NN's data structure is the Component, which is simply the user-defined text that may be inserted into a note. Components belong to specific Categories and are only available when that Category has been selected in the WYSIWYG editor.

Context names must be unique within the OpenEMR instance, but the same Category names and/ or Component content may be used in different Contexts. It may make shared templates confusing but it is allowed.

This Form

The steps in this Sample NationNotes LBV Form document create a very simple admission note of a patient in acute substance abuse withdrawal. Two NN fields are used: a Nursing Note and a Provider Note. Each has two Categories; each Category has a varying number of Components.

This Sample is built in five steps:

1. Plan the data structure
2. Create the LBV form
3. Create the Contexts for all NN fields
4. Configure the Categories of each Context
5. Create the Components for each Category

Plan The Data Structure

Plan the structures of the NN fields in advance to avoid confusion when building a NN form of any complexity.

• The only text of the "3 C's" that will appear in the note is the Component text.
• The Context is the name in the List list and may be assigned to any NN field.
• The Category is strictly a visual reminder of what sort of information is being entered into the note.

Form Name: DetoxAdmit

NN Field #1 Label: Nursing Note

Context: Nsg Admit Note

Category: Admit Interview

Component: Admit Vitals: BP:_____ T ___ P ___ R ___

Component: Intoxication rating:

Category: Psychosocial

Component: Subst Abuse History:

Component: Highest education level:

Component: Employment History:

NN Field #2 Label: Provider Note

Context: Prov Admit Note

Category: Phys Assessment

Component: Withdrawal Status Assessment:

Component: HEENT:

Component: GI:

Component: Resp:

Component: Integumentary

Category: Treatments:

Component: Phenobarb Protocol x 7 days

Component: Suboxone Protocol x 3 days then Phenobarb Protocol x 5 days

Component: Librium Protocol x 7 days

Component: Re-evaluate status in 24 hrs

On to Part 2, Building the Sample NationNotes Form