Drowning in documentation? Get your consult notes done in a fraction of the time (Template Series 2/3)

Make your documentation more efficient. Look at your last few consult notes for a given presentation. Congratulations! You already have a skeleton for your template. 

Note: EMR (electronic medical record) and EHR (electronic health record) are interchangeable.

What Documentation Piles Up In Most Practices

Think about your documentation for a minute…which notes take you the longest and drain your clinic efficiency? Which ones are the easiest to be left? What seems to be piling up the most on your to-do list? 

For me, it was consultations / first visits with a new patient. You too?  

Those first appointments are longer for a reason. We’re getting a full view of this patient, including their medical history, medications, allergies, physical examination and treatment plan. Sometimes we’re also documenting sensitive information and coordinating with other specialties.

*takes deep breath after reading all that* It’s a lot of information, and often, a lot of time.  

You’ll be unsurprised by this next statement…have you considered making a template? 

If you’re brand new to templates, follow-up notes usually require less up-front time investment and are a great starting point.

If you’re a self-proclaimed template addict (ahem, yours truly), a hugely high-yield category is consult notes. Or in a primary care setting, the first visit about a new problem. 

Warning: Consultation Templates May Contain “Note Bloat”

Before getting too excited, beware of one of the criticisms of templates: note bloat.

What’s note bloat? It’s exactly what it sounds like – adding excessive or unnecessary information to your notes.

I strive to have my templates reflect the actual flow and language I use during any given consult. That way, the notes stay lean, accurate and effective. 

But every patient is unique…

Every patient is unique. They have their own story, and it’s so important to capture that nuance. You can’t just paint everyone with the same brush. 

Absolutely! Couldn’t agree more. However, for a given problem, you still review the same questions on history, complete a similar exam and discuss the same (or almost the same) options for prevention, treatment and risks.

If you’re still not sold, try looking at the last three consult notes you’ve done for a given presentation. Chances are they’re pretty similar.

Say hello to your template. 

If you’re still concerned about losing personalization, think about completing a consult note where most of the information is already there. It’s a lot easier to add the nuance because you don’t need to rhyme off your standard information. 

How to Create Templates For Each Type of Consultation 

Organize and word your template as you would dictate it for this imaginary patient. Go back to your last few consultations for a presentation – it’s going to be really helpful in giving you the sort of flow and wording that will make sense for your practice.

Remember note bloat? It’s important to review the template and make sure that all information is accurate and relevant…it should contain what you actually review with patients.

I firmly believe that a template can be worded to serve as a base for all patients with that presentation. Think about it: you review the a lot of the same information for a newly diagnosed DM2, an inguinal hernia or 36-week obstetrical check-up. 

What if this consult is different, and I don’t have an existing format?

Is your template going to work 100% of the time? Probably not. But don’t worry, all is not lost. 

When and where you want to add nuance and personalization, you can set up your template to add freehand text or dictation.

(Note: if you’re not sure how to start, most EMRs have videos online on how to set up a template. A quick Google search will pull up a straightforward, step-by-step video that even the most non-techy can handle.)  

Like pre-populating my standard forms, I went just a tad overboard with this. Okay, maybe a lot overboard.

No regrets, though, because now I have a template for almost every type of consult. For a really unique presentation, I have enough variety to use a closely related presentation as a base, and I can modify it accordingly.

No matter what pops up, time is being saved.

Worst case? If a specific case warrants it, old and reliable is still there: you can still dictate a whole new note. And it feels much less taxing when you rarely have to do it. 

Start Here: Your 3 Most Common Consultations / First Visit Appointments

If you’re new to templates, don’t overthink it. Start with one of these: 

• Your 3 most common consults or first visit for a given problem you see;
• The 3 consult types you like writing/dictating the least; or 
• The consultations that are on your to-do list for tomorrow.

Like any of our ideas, the point is to get started! You may have to tweak as you go along, but you’ll start seeing the benefits immediately: save time, reduce daily repetition and close that EMR earlier. 

How do you feel about templates for consults / first visits? If you’ve made some recently, have you noticed a difference in your documentation time? Let us know!