I have to admit for most 99213 without giving a lot of thought to labs, I can chart a note in about 90 seconds. My MA enters everything on the left side except the meds. I do add a little to the HPI which already has all the pertinent ROS. I use a template to cover all the other as long as I get 2 - 9 ROS and 4 bullets in the HPI which sets up a 99214 if I get to the right exam and decision making level. The PMH and PSH and allergies generally stay the same. I always open the meds and make sure they are still on the same which, again, they are usully one.
Yes, I do use templates for the exam. I guess I could dictate and/or use drill down EMRs like Logician, but that would take forever althouh it has the advantage of computerized coding. I personally don't see anything wrong with having the same exam documented if it is a left otitis media as long as I try very hard to make sure I document a murmur. Of course, there is always a chance I forget or miss something. I remember reading about one doctor who was documenting a testicular exam on both male and female patients.
The diagnosis is simple, and the antibiotic takes only a few seconds (if you have a good database - which I have but no one wants, lol). If I do have a lot of labs or management it takes longer, but that is usually a 99214.
With managed care and insurance companies paying less and less, we are forced to see more and more patients. I would love to dictate a three-page note like a consultant does, but they are seeing five to ten patients a day max - probably less.
Of course, I have been using AC for over three years now.
Just my experience.
