I use templates and Short Keys heavily. I have templates set up for routine diabetes follow up, HTN follow up, cholesterol, etc. I also have them for the acute illnesses such as bronchitis. A simple "Also," typed before each new template is sufficient. And, I delete or add pertinent info as it pertains to that particular patient at that particular visit. I may use 2-4 different templates in the history section of the same note. My physical exams are also templated according to problems. I probably use the diabetic one the most for most routine follow-ups and just delete parts like checking their vibratory sensation if they have returned for bp follow up. I can be charting in the room while the patient is giving me their complaints and 90% of the time my note is finished before they are. While I am personalizing the note, they can feel like I have taken the time to really listen to them. After the exam, I "correct" any items I need to in the physical template, list the problems in the assessment, Short-Keys a plan, fax scripts, orders and notes to colleagues, print the note up front and I am out of the room. Again, I do all of this in front of the patient. I really believe they benefit from seeing the work you put into their encounter. By the time the patient gets to the checkout desk, the staff is already making their return appointments and setting them up for any special tests or referrals.
Leslie
