Home Forums Discussions Problems Facebook link from Jon Bertman

Jon Bertman's discussion about the EHR, templating, and rubber stamping. EXACTLY what I have since the first time I saw an EHR, and why I hate templates.

http://link.brightcove.com/services/player/bcpid1247065303001?bckey=AQ~~,AAAAAmAuE5k~,yPOiW1tAnh8VFxtTJZKoCxx8dh7oIzO5&bclid=1247014046001&bctid=1251491405001

What generally works for me is to avoid templating a whole exam, or an entire history section. If your template is a specific phrase, or for negatives a single system, you should avoid the gross errors that Dr. Bertman mentions.

John,

Can you be more detailed? I am not sure what you are describing?

@David

With addresses that cumbersome, it may help to use tinyurl to make them more manageable and make them hot links, although this one needed a redirect, which was weird.

http://tinyurl.com/bertman-templates

Thanks Bert. That was not in my bag of tricks. I'll try to remember.

What Dr. Bertman is describing is templating the entire encounter note for each disorder, so that it reads the same every time. A diabetic patient would have the same note for each visit. Very obvious to an auditor.

What I am trying to do is have a phrase or set of sentences that I can insert, mostly as pertinent negatives (i.e.: Diabetic foot exam template "Sensation on soles checked with monofilament and intact. DP & PT pulses present bilaterally. No foot ulcers".) Of course I don't use the template if the exam is abnormal, I just Dragon dictate that part of the exam. In the average 9 or 12 component PE, more than half of the systems are normal, and can be rapidly added by templates. The same is often true of pertinent problem negatives in the history or ROS.

John,

What you are doing works fine. Judging by the notes I receive from other offices, however, that is not how it usually goes. I get way too many notes where the provider punched the "diabetes button" and let it rip.

I also personally find it more time consuming and tedious find a bunch of templates and mouse-click my way through everything than to just use Dragon and say what I'm thinking. Even when I read my own notes, when I have used templates I don't trust them completely... was there really no murmur there last time, or did I just mindlessly click my way through it? Even if I use a "mental template" when dictating, I have to at least momentarily engage my forebrain when mentioning something. The same is not true for me when template clicking.

True, I don't know how many times, I have referred a kid to a cardiologist after saying RRR with no murmurs, gallops or rubs.

I guess I could say, "Just wanted to make sure."

Praxis?

David,

I often do what you do, just dictate with Dragon. As we both know however, this isn't foolproof. If you are not careful and speak clearly, you will dictate "59 year old man for annual comprehensive exam" and Dragon will type "59 year old man for manual insensitive exam" or something equally ridiculous.

I combine a lot of templates, (IE: for a diabetic foot exam)

Feet: Bilateral exam reveals no open wounds, or skin breakdown. There is hair present all the way to the toes. The dorsalis pedis pulse is 2/4 and equal bilaterally. Monofilament testing reveals the patient to be neurologically intact with pinpoint discrimination all the way to the toes.

With editing that is typed IN ALL CAPS. We find this useful for several reasons. When I glance back at my note before signing the CAPS show I have edited the note, and when my Partner or I read each other notes, we can quickly find the pertinent parts:

Feet: Bilateral exam reveals ERYTHEMA AND MACERATION BETWEEN THE FOURTH AND FIFTH TOES ON THE RIGHT FOOT CONSISTENT WITH TINEA PEDIS. There is NO hair present all the way to the toes. The dorsalis pedis pulse is ONLY TRACE and equal bilaterally. Monofilament testing reveals the patient to be neurologically intact with pinpoint discrimination all the way to the toes.