Terry, since we're both Internal Medicine, I'll throw in things I found when I started.

I really had some trouble at first adapting and getting my note to show useful information. I found it useful to print out a few, and look at it the way an outside party would look at it. Then I modified what sorts of things I put where.

I also got rid of most of the templates that came with AC. Some folks seem able to use templates extensively even in an Internal Medicine practice, but they just did not seem to fit what I was doing as an internist. I did make up some templated physical examinations, and that is useful, and some introductory information discussed in the "template %" and "Placeholders in templates" threads gets used in the HPI. The rest gets dictated in using Dragon Naturally Speaking.

I will say that on those occasions when I see someone with a headcold or backache the templates are wonderful, but that is not what I see in my practice.

I get way too many records from other practices that have several pages of templated information that you KNOW were never addressed. My favorite is a practice that insists it asks if the patient has been incarcerated on every visit. I really, really don't want my records to look like a robot did them.


David Grauman MD
Department of Medicine
Commonwealth Health Center
Saipan, Northern Mariana Islands