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Documentation Tips and Tricks

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  • 2 weeks later...

Make it so a normal physical exam populates automatically into your note. 

Save templates for normal assessment and plans: "hypertension has been stable, tolerating lisinopril without side effect. Continue to work on diet and exericse. Follow up CMP in 6 months". Adjust as necessary.

Let your MA/LPN work to the top of their scope. Train them to call patients with normal labs/imaging/etc.

Get dragon if you do not have it. Worth the investment. 

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Thanks for all of the tips. My EMR allows shorthand (aka dot phrases) so I have been using a lot of those. Because I am new I have been using the standard templates but I think I need to customize them to make them even more efficient. It does definitely depend on the MA too - some of them are awesome and I barely have anything to add to or change in the HPI. 

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  • 1 year later...

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