I have many multiple problem patients. I do use templates in almost all sections of AC. I use Dragon to dictate the edits.
In the history section, I have a template with pertinent positives/negatives for all the major chronic conditions, ie: diabetes, HBP, high lipids, UTI, URI, DJD, etc. I pull up a template for the first condition, modify it with the patients responses -- done. Next condition or complaint is a new template, edit, and so forth. The patients sometimes just hand me their list after they are done, and I use their info for my edits. Believe me, if you just use the patient's words, it won't look like you pasted in a template.
It definitely saves time to use templates in the ROS, and you can change terms if you don't want it to sound canned. If you want to put in both a cardiac and pulmonary ROS mentioning the same symptom in both, set up one to say dyspnea and the other shortness of breath. Similarly, swelling or edema, chest pain or discomfort, and so on. I have also seen my partners survive an audit without downcoding by simply stating "No change in this patient's review of symptoms otherwise since 3/10/10", or whatever date a complex level ROS was recorded.
I then tab through the PMH, SH, FH sections and modify if new info. In the CPX, I have a 9 or 12 system exam templates, again go thru each entry and edit. How many of us really change our exam procedure anyway -- we check the same areas on every diabetic, hypertensive, etc -- just different findings. I think its also a good guideline for your exam, if you set up the template to meet accepted standards.
The advantage of addressing each problem, with a separate paragraph in the history, is not only rapid entry by using a template that you can edit-- it organizes the problem list for you, and verifies that you addressed several distinct stable or new problems. This should almost always give you a level 4 visit, if you have sufficient decision making, prescribing, lab review, etc in the assessment/plan section.
I am envious of you who are fast typists. But customizable templates are a life & time saver for me, and one of the real strengths of AC.
