Diabetes Educators Calgary Charting Guidelines
Department Smart Phrases and Links
Department Smart Phrases and Links
Charting guidelines are intended for use by Diabetes Centre Calgary clinicians. This page is in development - ongoing updates are being made.
DCC staff are expected to use standard department Smart Phrases for notes and communications. Delete text that is not applicable. Add free text sparingly, as needed.
- Information that has a dedicated field (e.g. weight), should be charted in that field. The Note pulls the information, so that you do not need to double-chart.
- Standard Smart Phrases help Educators:
- To focus on important issues
- In regards to checklists, e.g. Safety check list
- Consider the order of the data, in helping to make review of data easier.
- For decision support [e.g. glucose targets] – a live link is inserted into My Note. Using <Ctrl> + click will open the link.
Table of Department Smart Phrases (DCC and DIP)
- Use the search box at the top right of the table to find the phrase you're looking for. Non-DIP phrases start with DCC and DIP phrases start with DIPC
- IDNN-specific Smart Phrases are listed on our 'Specialty Specific" page.
- Phrases can be combined. For example, for patients who use a real-time CGM, typing .dcccrtcgm will add the skeleton of CGM parameters that are useful to include in your note.
| Name | Description |
|---|---|
| DCCCAISHLetter | To generate a letter to provide to the patient for extra AISH funding for special diet. |
| DCCCCGM | CGM parameters for patients using a continuous glucose monitor |
| DCCCDietitian | Diabetes assessment or follow up by dietitian |
| DCCCDischargeForMD | Discharge note to send to MD |
| DCCCDischargeForPt | Discharge note to give to patient |
| DCCCEntryClass | To generate a note to send to the referrer, regarding attendance at the Entry Class |
| DCCCInsulinStart | To document instructing a patient on an insulin start |
| DCCCIntake | For Intake Appts (pilot project) |
| DCCCMissedAppt | Informing external MDs about missed appointment. |
| DCCCNotIndicated | To request an order to adjust meds with no indication to be used in combination. |
| DCCCNurse | Initial diabetes assessment by nurse |
| DCCCNutritionDiagnosis | To add nutrition diagnoses to Note |
| DCCCPsychNote | To document Psychology appointment. |
| DCCCPump123 | To document FU from pm on Days 1, 2, 3 after new to pump start. |
| DCCCPumpFUorIPTPReview | To document a routine pump FU - OR- an IPTP Annual Pump Review. |
| DCCCPumpInstructionsDoses | Patient instructions and pump doses for new pump starts. |
| DCCCPumpPrepBasic | To document basic prep items�covered today (any DCC educator) and outstanding items to prepare a patient to see a pump educator. |
| DCCCPumpStart | To document a pump start by CPT |
| DCCCPumpStartOrders | To request insulin pump start orders for a new pumper |
| DCCCREQFORINSULIN | To request insulin orders |
| DCCCQuickTemplate | A short, bare-bones note for frequent patient contacts |
| DCCCREQUESTREFERRAL | To request a current referral for a patient. |
| DCCCTravelLetterInsulin | Travel letter for patient on insulin injections |
| DCCCTravelLetterNoInsulin | Travel letter for patient not on insulin |
| DCCCTravelLetterPumpCGM | Travel letter for patient on pump and/or CGM |
| DIPCGDMClass | To document attendance at a GDM Class |
| DIPCGDMDietitian | GDM assessment or follow up by dietitian |
| DIPCGDMNURSE | GDM assessment or follow up by nurse |
| DIPCInsulinClass | To document Attendance at a DIP insulin start class |
| DIPCInsulinStart | To document instructing a DIP patient on an insulin start |
| DIPCMissedAppt | Informing external MDs about missed appointment at DIP. |
| DIPCPPNote | Post-partum progress note. |
| DIPCPPAmharic | Calgary postpartum letter translated into Amharic |
| DIPCPPArabic | Calgary postpartum letter translated into Arabic |
| DIPCPPChineseSimplified | Calgary postpartum letter translated into simplified Chinese |
| DIPCPPChineseTraditional | Calgary postpartum letter translated into traditional Chinese |
| DIPCPPEnglish | Calgary postpartum letter in English |
| DIPCPPForMD | Postpartum letter to the MD |
| DIPCPPFrench | Calgary postpartum letter translated into French |
| DIPCPPPunjabi | Calgary postpartum letter translated into Punjabi |
| DIPCPPSpanish | Calgary postpartum letter translated into Spanish |
| DIPCPPTigrinya | Calgary postpartum letter translated into Tigrinya |
| DIPCPreConceptionDietitian | For dietitians to document a pre-conception visit. |
| DIPCPreConception | To document a pre-conception visit. |
| DIPCT1T2Dietitian | Type 1 or Type 2 assessment or follow up by dietitian |
| DIPCT1T2Nurse | Type 1 or Type 2 assessment or follow up by nurse |
| .DCCCNoteToProviders | Paste in Medication Review if you notice providers charting insulin doses there, instead of in Insulin Instructions. |
| .KHDM1Overview | To insert data entered in the "Diabetes Problem List SmartForm" under the Diabetes Management tab plus wording to indicate the risk of euglycemic DKA in T1DM and pregnancy. |
Additional Smart Links
Smart Links are similar to Smart Phrases, but are shorter and system-wide. There is no need to add them to your personal list. To include a Smart Link in your note, type the link (e.g. .pmhpnn to insert medical history) in the appropriate spot in your note.
| Link | Description | |
|---|---|---|
| .activity | Activity information from "Social Determinants of Health" on Storyboard | |
| .add | Patient's full address | |
| .alchxp | Alcohol history in prose format | |
| .alg | Allergies | |
| .AnnualIPRevDate | Date of the last documented annual pump review | |
| .REVFSTIM(100304) | Capillary blood glucose readings entered on the Diabetes Management tab. | |
| .dmcgm | Displays Continuous Glucose Monitor (CGM) metrics entered | |
| .dminsulinmetrics | Displays insulin metrics: total daily dose (TDD), % basal and % bolus, if entered | |
| .dmsfptlvl | Patient level Smart Form data, including pump documentation (Pump brand/model, IPTP client: Y/N, IPTP Start date) | |
| .dmtargets | Displays glycemic targets entered | |
| .dob | Patient's date of birth | |
| .drughxp | Drug history in prose format | |
| .flow[22278 | Foot screening elements for right foot | |
| .flow[22210 | Foot screening elements for left foot | |
| .fname | Patient's first name | |
| .gtpalp | Gravida, Term, Para. Aborta, Living. Format: G8,T1,P3,A4,L3 | |
| .HMSummaryWithComments | All Health Maintenance Topics with due date and comments� | |
| .FLOW[10554) | Displays Hypoglycemia data entered in that section on the Diabetes Management tab. | |
| .LLABV1Y[*** | Latest specified lab value if done within the last year. For the *** specify which values you would like pulled. | |
| .lname | Patient's last name | |
| .name | Patient's full name | |
| {IP FN NUTRITION DIAGNOSIS FLOWSHEET:3047689} | Displays PES statement created from the nutrition diagnosis. | |
| .pmhpnn | Past medical history in prose format | |
| .pnotes | Pastes "My Note", e.g. into supplementary letter. | |
| .resulast[HbA1c | Latest A1c result | |
| .REVFSTIM(104674) | Safety chcklist items covered over time, includes dates | |
| .tobhxp | Tobacco history in prose format | |
| .downtime | To indicate that there was a CC downtime and alternate charting was done. | |
| .flowamb[11 | Height | |
| .flowamb[14 | Weight | |
| .flowamb[1 | Vitals, including height, weight, BP, Pulse | |
| .lastbmi[1 | Most recent BMI | |
| .patinstr | Insert Patient Instructions | |
| .problistapoverview | Medical problems with Overview, Assessment and Plan. Edit out unneeded information. | |
| .sexhxp | Displays "Sexual History" data from "Substance & Sexual History" (including contraception) in prose format |
My Note Smart Phrases
To add smart phrases and customize your speed buttons:
- The first time that you use a specific Smart Phrase, add it to your list of available phrases
- Go to 'Smart Phrase Manager' > 'SmartPhrase Lookup'
(find SmartPhrase manager by using search tool top right of Epic green bar) - Make sure that the box 'Search Only Phrases I Can Use First' is unchecked
- Search for the phrase you want to add (see the table below)
- Select the phrase, then click Accept
- In the Sharing area, click 'Add Me'
- Go to 'Smart Phrase Manager' > 'SmartPhrase Lookup'
- Open the patient chart.
- Go to 'My Note'
- In the Note free text box, start typing the name of the Smart phrase starting with a dot, e.g. '.DCC'
- As you type, the list of available phrases will be filtered. Select the one that you want by double-clicking.
- If this a phrase that you use often, add it to your list of speed buttons, as described immediately below.
Customize My Note Speed Buttons
You will use certain Smart Phrases often, so it's useful to be able to choose them quickly. Make sure you add them to your available Smart Phrases first, as described above. To customize your Speed Buttons:
- Open the patient chart.
- Go to 'My Note'
- Click on the wrench icon at the top right of the Note section
- In the dialogue box the comes up, type the desired SmartPhrase in the SmartPhrase text box at the top, then click 'Add'
- In the 'Caption' box immediately below the Smart Phrase you added, give it a shorter name, meaningful to you, so that the button takes up less space.
External Communication Smart Phrases
Includes reports to physicians not on Connect Care and other documents not routed directly through Connect Care. When reviewing the chart, under Chart Review > Encounters, there is a record of all communications sent.
- Complete "My Note" and Accept.
- Go to the Wrap Up tab > Communications > New Communication.
- Select the recipient
- For family doctor: PCP
- For Psycho-social team, use "Free text" and input DCC fax number (403-476-9626).
- Choose what you would like to send:
- For physician: "Send Notes"
- Modify the note as required.
- Click "Send Now."
Making Smart Text Editable
Within Smart Phrases, certain text shows highlighted in blue. It may appear that you are not able to modify or delete part of the blue text. But you can edit it:
- Right-click on the highlighted text or table.
- Choose "Make Selected Text Editable" then modify it as needed.
- For tables, select "Edit Smart Link Parameters". You're able to choose how many columns you want to display, and the order of the columns.