rknowle Posted August 12, 2017 Share Posted August 12, 2017 I am a new graduate working in rural family medicine. I am struggling to find the balance between efficient yet complete documentation and was wondering if anyone had any tips or tricks that they use and find helpful. Thanks in advance! Link to comment Share on other sites More sharing options...
Max PA17 Posted August 13, 2017 Share Posted August 13, 2017 I'd like to piggy back on that and also wonder if there is a good direction to focus studies, or any good resources that would be most helpful to us new PAs in family med. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Arthropathy Posted August 23, 2017 Share Posted August 23, 2017 Templates for your most common diagnoses. HPI, ROS, physical exam, plan, f/u. All in 1 template. I have about 30 templates. The trick is to minimize the number of clicks to get through the note. Put a * in the few spots that need individual attention. Link to comment Share on other sites More sharing options...
dchampigny Posted August 26, 2017 Share Posted August 26, 2017 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. Link to comment Share on other sites More sharing options...
rknowle Posted August 26, 2017 Author Share Posted August 26, 2017 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. Link to comment Share on other sites More sharing options...
Phoenix88 Posted December 6, 2018 Share Posted December 6, 2018 Know the rules behind coding and how much documentation is required. You really don't need a lot of writing for a simple visit. Technically, you don't need too much history for a level 4 visit. If you know the rules, you can make better judgements on how much is enough. Link to comment Share on other sites More sharing options...
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