Home Forums Discussions General Discussion Charting Efficiency

What have the forum users found to be the most efficient methods of charting in AC? What are the tricks and tips you have found make the most difference? Lastly, are any of you able to chart daily, or does everyone stay behind?

Thanks

Charles

Hi Charles,

You are asking all of the key questions, I am not sure anyone is going to give you real great answers. I can address your last point, though "Perpetually behind".

I am guessing you are using some type of voice recognition. Dragon is way way faster than keyboarding.

The main issue involves templating. I cannot template HPI or plan, these have to be free text. So many times, especially with older patients with multiple problems, these can get long and involved. I do not know any way to streamline that.

Other practices will tend to template heavily. They produce very long notes, with lots and lots of words, and very little useful information.

Then, of course, comes the documentation required for prior authorizations. This is becoming more and more burdensome, medications and procedures increasingly requiring authorization, which requires detailed documentation.

Gene

Hi Charles,

I agree with Gene. Every practice have its own way of documentation.
I use combination of Dragon Dictation, typing and using ShortKeys along with having templates as we go. I am able to finish my notes at the end of the day - about 30 minutes after seeing my last patient. However, it also depends on how many patients you see in a day. I see about 12-13 patients in a day.

HPI and Plan needs attention for documentation related to the visit, more than other fields which my office staff help to fill in before me going to see the patient.

Now with Telehealth visit, I have to finish all fields myself without my staff doing any prior work - checking medications and updating Past history / family history if any new info has emerged in the interim time.

I saw on AC Website, how we can train Dragon to work faster with AC, but I have not been there yet.

Qaiser

AC is a template based EMR when it comes down to it. In many years, I have built up a vast list of templates for almost every diagnosis I see frequently. There are some canned ones you can access with AC, but with the thousands of doctors working with AC, I'm surprised they don't include a much better sampling with the EMR.The few that are built in are really lame. If you take the extra time, every time you see a common dx, just make a details write up and save it as a template for the assessment section.

Hi Chris,

I am very interested in how you do this. It seems like so many of my visits are "Recheck coronary artery disease/hypertension/diabetes/cholesterol" when the patient is actually far more interested in talking about their knee that hurts and their difficulty sleeping.

Do you combine 6 separate templates? Try to make one template to cover the next time someone comes in with these 6 problems? Or just pick one, use that template, and free text the other five in?

Thanks.

Gene

There used to be a collection of templates from a lot of users. I had put a number of my templates there. It was not well organized but there were over a 100 templates there.
It apparently no longer exists that I can see. Probably when they "updated" the website. They are saved as .xml files and can be exported from the template box. You can modify templates in a sub screen to the template screen to meet your needs.

Theoretically you open the template box (control T from one of the categories) and there is a section that states Import a template (from AC or from Local Folder). If you click on that folder it should take you to the webpage but it takes to the generic "front door" of the AC website. I googled amazing charts templates and no luck either.

Sure you can combine templates. I have several different types of templates. Some are most of the text I would ordinarily type. Some are reminders to check various items (do you remember all of the cranial nerve checks?) Most of my notes include free form and templates, and yes, sometimes more than one template which then I would modify to meet needs. Even in Pediatrics we frequently have multiple medical problems addressed at the same visit, this makes it easier.

To make a template you use the alt button and the Right click button on your mouse. It will then copy all of the text box into the template field, which then you need to label the template. You can add / subtract / change the information in the template box to be more generic for future visits. When you write that perfect note for a type of visit, this keeps it easy to repeat.

Hi Wendell,

I looked through my website copy of the old AC forum, but I couldn't find the templates.

Can you suggest some XML title for me to search for? (FROG_WARTS_TEMPLATE.XML, for a silly example.)

***

Unfortunately, the non-main forums may have been cleaned out when AC decided to abandon the board, leaving just the two or three files that we now see.

Here's a screenshot of what seemed to be left in the "helpful downloads" forum back then:

[img]https://www.dropbox.com/s/g5hovfv1vk5wfbf/no_downloads.JPG?dl=0[/img]

Cheers,

Carl Fogel

Never mind, the WayBackMachine may have the "templates" that Wendell has in mind:

https://web.archive.org/web/20120619183610/http://amazingcharts.com/ub/ubbthreads.php/forums/4/1/Helpful_Downloads

Posts from "roy" and "vinnemeyer" and others have this sort of stuff:

%FNAME will use OTC medications for the balance of %his symptoms. %He was instructed to call or return if %his symptoms worsen or do not improve over the next few days, othewise we will see %FNAME for follow up PRN.

So far, the WayBackMachine doesn't show any of the attached xml files, but the posts may be enough for users to cut and paste and re-create templates.

I'm happy to share, but my templates are the way I do things, and you probably do it different or better. Right click in the HPI and then type in the box instead. Click Save As New and name it. For instance,
*Telemed
Patient presents via Telemed because of the threat of the Coronavirus pandemic. Patient consents to the possible loss of privacy in being seen this way, and consents to the less than optimal situation for physical exam.

*New Anxiety
CUXOS Anxiety Scale:
(0 = not at all true; 1 = rarely true; to = sometimes true; 3 = often true; 4 = almost always true)
During the PAST WEEK, INCLUDING TODAY:
1. I felt nervous or anxious:
2. I worried a lot that something bad might happen:
3. I worried too much about things:
4. I was jumpy and easily startled by noises:
5. I felt keyed up or on edge:
6. I felt scared:
7. I had muscle tension or muscle aches:
8. I felt jittery:
9. I was short of breath:
10. My heart was pounding or racing:
11. I had cold, clammy hands:
12. I had a dry mouth:
13. I was dizzy or light headed:
14. I felt sick to my stomach (nauseated):
15. I had diarrhea:
16. I had hot flashes or chills:
17. I urinated frequently:
18. I felt a lump in my throat:
19. I was sweating:
20. I had tingling feelings in my fingers or feet:

SCORE:
0-10 not anxious
11-20 minimal anxiety
21-30 mild anxiety
31-40 moderate anxiety
41 and above severe anxiety

(Zimmerman, M., Chelminski, I., McGlinchey, J.B., & Posternak, M.A. A clinically useful depression outcome scale. Comprehensive Psychiatry, 2008, 49, 131-140.)

*ADHD
ADD/ADHD Safety:
Patient presents with complains of difficulty concentrating [AND] impulsive behavior. The historian is a parent.
Parent states he does not have:
heart disease, heart rhythm disorder;
coronary artery disease (hardened arteries); or
history of heart attack;
high blood pressure;
a personal or family history of mental illness, psychotic disorder, bipolar illness, depression, or suicide attempt;
peripheral vascular disease such as Raynaud's syndrome;
epilepsy or other seizure disorder;
tics (muscle twitches) or Tourette's syndrome;
a stomach disorder; or
a history of drug or alcohol addiction.

*Tension HA Episodic
Infrequent, Episodic Tension-Type HA (IHS)

Description:
Infrequent episodes of headache lasting minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, and it does not worsen with routine physical activity. There is no nausea but photophobia or phonophobia may be present.

Diagnostic criteria:
A. At least 10 episodes occurring on <1 day per month on average (<12 days per year) and fulfilling criteria B-D

B. Headache lasting from 30 minutes to 7 days

C. Headache has at least two of the following characteristics:
1. bilateral location
2. pressing/tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity such as walking or climbing stairs

D. Both of the following:
1. no nausea or vomiting (anorexia may occur)
2. no more than one of photophobia or phonophobia

E. Not attributed to another disorder

That's just the HPI box. You can do templates for every box Assessemnt box especially.
Just some examples:

Dx: CT Syndrome
# Carpal tunnel syndrome (G56.00): I explained the nature of this condition to the patient.
1. Start with avoiding offending actitivities at work or at play. Make note of ergonomic problems to fix. Consider an anti-inflammatory and ice/heat therapy.
2. Get a brace to wear, at least through the night, but consider during the day.
3. Next, consider injection therapy if not better in 3-6 weeks.
4. Finally, consider surgery if this is needed. We discussed the anatomy and what a surgical release would involve.

Dx: Hepatitis, transaminase elevated unkown cause
# HEPATITIS UNSPECIFIED:
I have discussed the most common causes of mild elevation in liver transaminase levels. The initial workup includes a variety of tests for possible causes.
1. Alcohol Related: patient does [not] drink excessive amounts
2. Hemochromatosis: may check iron, ferritin, and TIBC levels
3. Hepatitis B, C: may check viral hepatitis panel (HBsAg, Hep C ab)
4. DM: CMP, A1C, Lipid Profile, PT/INR
5. Medications: Tylenol, Herbs, others
6. NAFLD: evidence of metabolic syndrome,

Next visit: Obtain ultrasound or CT scan, or MRI
Recheck CBC, CMP, T-bili, Insulin Level

If Chronically Elevated of Fam Hx Cirrhosis:
Check for other Less Common Causes:
alpha-1-antitrypsin deficiency (may check level)
autoimmune hepatitis (ANA, Sm Muscle ab testing)
Wilson disease (cerum ceruloplasmin level)


Extra-Hepatic Causes:
Celiac Dz
Hemolysis (G6PD Def, Sickle Cell, Infect)
Muscular Disorders
Thyroid Disorders

Treat Underlying Disorders such as DM, Lipids, HTN, OSA and measure LFT q3-4 mo.

Initiate Lifestyle Changes
Metformin for DM
Pravachol or Lipitor for Lipids

Statin okay with increased LFT, recheck in 2 weeks and monthly x 3. Stop if LFT more than twice baseline.
If transaminases twice normal, then biopsy
AAFP 11/2011 7/2013


In One Year: If continues elevated, consider non-invasive fibrosis test and additional imaging. Refer if positive to GE

Hi Chris,

Thanks, impressive stuff.

So, for an older patient with multiple problems, how long does the note turn out to be?

Thanks

Gene

I don't think it would be a note at that point. Very impressive.