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Hello everyone, our office is preparing everything for getting started with amazing charts/lytec within the next two weeks or so. I've been working hard to try and setup templates and customizing so it will be easier to use. Anyone have any templates made that are pulmonary related

Hope Everyone has a great day.

Thank you

Welcome to AC. Wish you well getting everything up and running. For templates, take a look at some of your past consults and formulate your templates from those that will be the easiest thing to do. It will be in your own verbiage. You are much more organized than I was.

Robert,
I would agree with Tom's advice. Here is my (more verbose) explanation which applies to pulmonary as well as GI.

Thanks for the help! Mainly I've been looking at past consults, H&P, f/u notes to make a nice set of templates. Looking good so far, just time consuming. Soon, very soon

Question for the "pro-template" crowd from the "anti-template" holdout.

How do you get templates to flow together? If you have one that says" The patient denies orthopnea", and one that says "The patient denies productive cough" and one that says "The patient denies any significant ankle swelling" and you just choose those three, for example, it is as obvious as all get out that you took a cookie cutter and pasted the results together, since you would never write that like that if you were dictating. If you say "the patient denies X, Y and Z" then you are starting to cram the patient into the dictation ("well, he had a little ankle swelling, but the template doesn't say that, so I'll use the template I have.") If you have a template that says "The patient denies" and then ones that say "ankle swelling", productive cough, " orthopnea,", etc. and choose each one by one, then not only is it as much work to plow through a list of 50 or 60 items as just dictating the sentence, but you have the issue of punctuation (does your template end with a period or a comma, for example?)

That's a big reason I hate these things. I seem to only have a choice between blatantly generic and dreadful prose. I hear enough snide remarks from my consultants about the poor quality of some EHR records I am just terrified of joining their ranks. How do you all avoid this?

David, you are making the use of templates far too difficult if you have that many. Start with bigger templates, say one for pneumonia. Concoct one that states most of the things you see when you have a patient with pneumonia. For instance,
"The patient has had several days of worsening cough and congestion with production of discolored sputum. Fever and chills are present. Pleuritic chest pain is not present. Associated symptoms include myalgias and shortness of breath. Ear pain and hemoptysis and are not present. %He has not been immunized for pneumococcal pneumonia. %FNAME does not smoke . Chronic pulmonary disease is not present. There is no history of previous similar events. The review of systems is otherwise unremarkable."

"GEN:Ill but not septic with mild respiratory distress.
HEENT:Conjunctiva are normal. Tympanic membranes are clear with no effusions. Nose and throat are normal.
NECK:Supple with no meningismal signs. No unusual lymphadenopathy.
CHEST: Rhonchi are heard in the right base. Pleural rub is present.
CARDIOVASCULAR:Regular with no murmurs, rubs or gallops.
ABDOMEN:Soft with no hepatosplenomegaly.
NEUROLOGICAL:
EXTREMITIES: No joint effusions. Edema is absent.
SKIN: No rashes are evident."

Then you can easily personalize your template for each visit by removing (or adding)the "not"s and expanding if needed on the positives. I use ShortKeys if I just want to have 1-2 sentence macros, e.g. "rwe" turns into "The throat was red with lateral banding but there were no exudates". Or "sw" expands into "Scattered wheezes were heard throughout all lung fields".

Well said, Leslie.
And how about for normals....we have a normal ROS and male and female physical. If one or two things are abnormal, they are quickly changed in the note. Big time saver.

That's the way I do it in Iowa as well. It saves a lot of time and flows very well. I agree with David that there are quite a few template users out there whose notes are quite embarrassing to read. I have a cardiologist who comments on straight leg raising and sensory function to "pin!" Yet, If looking at my notes with AC and then you look at my notes from 10 years ago, they still flow very well.

Leslie, do you use Dragon? Maybe that's part of it. I've been using it for several years, and find it much quicker than your way would be for me if my history is going to be even a little customized. The difference is I am never comfortable doing it in front of the patient since the note often contains my private thoughts. ( the patient can get a copy any time, but I am not interested in having a debate at appointment time). I do use a template for the ROS and physical as you do, and PH and FH change so little it doesn't matter. I think Dragon is marginally better for those templates. I simply say " male physical" rather than right click - scroll - select - enter.

No, I do not use Dragon, for the very reason you mention. My notes are completed in the room and I do not like dictating in front of patients.