Physical is perhaps the easiest part for me. I try to be consistent all the time. So even though it is an earache, I listen to the lungs, heart and abdomen and check the abdomen. I note how they walk in and out and of course all the ENT things. So a template as a base works, with modifications as needed.

I have a large number of templates that are regional if I am only doing a knee or ankle exam but that is a small percentage.
H&P can be challenging. I do a lot of typing and I am fairly good at it. Some can be templated in, with the appropriate responses. I would agree that DNS is probably a better solution but often is slower than typing. (I have not used DNS in a long time, and I am sure it has made strides.)

ROS can be templated, you just have to change NO to + appropriately and delete those that were not asked. Some of these can be done by MAs as they get your initial information.

But what works for one may not work for all.


Wendell
Pediatrician in Chicago

The patient's expectation is that you have all the answers, sometimes they just don't like the answer you have for them