Diabetes Educators Calgary Charting Guidelines

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.

• Department Smart Phrases
• Additional Smart Links
• Using My Note Smart Phrases
  • Customize My Note Speed Buttons
• Using External Communication Smart Phrases
• Making Smart Text Editable

• 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.

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.

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'
• 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.

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.

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.

1. Complete "My Note" and Accept.
2. Go to the Wrap Up tab > Communications > New Communication.
3. Select the recipient
   1. For family doctor: PCP
   2. For Psycho-social team, use "Free text" and input DCC fax number (403-476-9626).
4. Choose what you would like to send:
   1. For physician: "Send Notes"
5. Modify the note as required.
6. Click "Send Now."

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.