Procedure Notes/Templates (transitioning from Epic)

[DrSwede]

So I left fellowship where we used Epic for our EMR, which included templated notes and the ability to "tab" through drop-down menus and make selections; this made it easy to complete the procedure notes quickly.

Now I have to use some other software for template generation, but I would also like to have the aforementioned functions included. I am fooling around with MS Word and can create drop-down menus, but have not found a way to "tab" through the drop-down menus. I cannot also select more than one option in a drop-down menu in Word.

Any recommendations, MS Word or otherwise?

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[Ducttape]

Talk to the IT people with the EMR and have them set up templates. You should be designing, them implementing...

Or set up a bunch of separate standard documents. Make a scattered few highlighted areas to put in specifics - ie location, med dose, fluoro time.


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[DrSwede]

I wish it worked that way. At this time there is no capability for a procedure note to be generated in the EMR, therefore it has to be generated elsewhere (ie Word) and scanned into the medical record. Also, we are not able to modify or include our own templates for H&P and follow-up notes...it's very bureaucratic here.

 

[DOctorJay]

Make dragon templates. Use macros. Dictate a few things here and there. (SSdoc's head is going to explode again because I mentioned Dragon)


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[DrSwede]

I do have dragon training coming up. I'll look into that, thanks.

 

[SSdoc33]

Make dragon templates. Use macros. Dictate a few things here and there. (SSdoc's head is going to explode again because I mentioned Dragon)


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you are dead to me

 

[melancholy]

So I left fellowship where we used Epic for our EMR, which included templated notes and the ability to "tab" through drop-down menus and make selections; this made it easy to complete the procedure notes quickly.

Now I have to use some other software for template generation, but I would also like to have the aforementioned functions included. I am fooling around with MS Word and can create drop-down menus, but have not found a way to "tab" through the drop-down menus. I cannot also select more than one option in a drop-down menu in Word.

Any recommendations, MS Word or otherwise?

what sort of practice setting are you in now?

I feel for you. I too had Epic in pain fellowship with heavily modified and specific templates that allowed us to breeze through stuff and also optimize billing. I went to work in a health care organization that also uses Epic, but heavily modified Epic such that all my pulldown menus and such do not work anymore and had to re-tool my templates completely. Pain in the butt

 

[Ducttape]

Forget the pull down menus with Epic.

It is easier to create smart phrases with the entire template complete except some very basic details (left/right/exact site/complication) that you can highlight.

I initially thought pull down lists were great, but still takes longer than necessary.


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[DOctorJay]

I use lots of "[ ]"s in Dragon. you can set up buttons on your dictation mic to jump around to these in your templates. I usually fill in some info inside of the [ ] that doesn't change often (like omnipaque 300 or whatever). I'll jump around, change what I need to and say "accept defaults" at the end. That will clear the [ ] for you and leave a normal looking note.

I used to dictate into a digital recorder for procedures only. I'm actually faster by setting up my templates like this with dragon and don't need to review and sign off on notes anymore. Saved our practice over $60k and saves me time. Win win.

 

[SSdoc33]

I use lots of "[ ]"s in Dragon. you can set up buttons on your dictation mic to jump around to these in your templates. I usually fill in some info inside of the [ ] that doesn't change often (like omnipaque 300 or whatever). I'll jump around, change what I need to and say "accept defaults" at the end. That will clear the [ ] for you and leave a normal looking note.

I used to dictate into a digital recorder for procedures only. I'm actually faster by setting up my templates like this with dragon and don't need to review and sign off on notes anymore. Saved our practice over $60k and saves me time. Win win.

you are out of your mind.

how can you get thru 30 patients a day like this?

 

[DOctorJay]

it's honestly so easy. I dictate just like I would with a digital recorder, same speed and everything. Rarely a mistake is made.

it's only possible with a quality hand held dictation microphone, the headsets are trash. I have a powermicII.

oh and I see more like 25

 

[Taus]

I use lots of "[ ]"s in Dragon. you can set up buttons on your dictation mic to jump around to these in your templates. I usually fill in some info inside of the [ ] that doesn't change often (like omnipaque 300 or whatever). I'll jump around, change what I need to and say "accept defaults" at the end. That will clear the [ ] for you and leave a normal looking note.

I used to dictate into a digital recorder for procedures only. I'm actually faster by setting up my templates like this with dragon and don't need to review and sign off on notes anymore. Saved our practice over $60k and saves me time. Win win.

I do the same. Key is templates with [variables ], "accept defaults" and lots and lots of self-made macros.


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[drpainfree]

you can create word file for procedure template. not too hard, look for drop-down list for word on google search, and learn how to use it. I do all my procedures notes with word templates.

 

[DrSwede]

what sort of practice setting are you in now?

I feel for you. I too had Epic in pain fellowship with heavily modified and specific templates that allowed us to breeze through stuff and also optimize billing. I went to work in a health care organization that also uses Epic, but heavily modified Epic such that all my pulldown menus and such do not work anymore and had to re-tool my templates completely. Pain in the butt

I do the same. Key is templates with [variables ], "accept defaults" and lots and lots of self-made macros.


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Ok, I'm going to try this. Just received dragon training and given a powermic II.

I am in a hybrid type practice setting. It's part private practice, academic, and community based medicine.

 

[Resident0123x]

Forget the pull down menus with Epic.

It is easier to create smart phrases with the entire template complete except some very basic details (left/right/exact site/complication) that you can highlight.

I initially thought pull down lists were great, but still takes longer than necessary.


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Ducttape, Do you have a set of smart phrases that you can share

 

[hyperalgesia]

My templates have all the variables defined at the top -positioning, levels, side, doses, etc. I don't see the benefit of tabbing through to put everything inside.