If you’re a doctor or other advanced practice provider, you probably spend at least 20 minutes clicking and typing on the computer for each patient you see in a given day. This is in addition to the 20, 30, or 40 minutes we spend actually meeting, assessing, and making treatment decisions for each patient.
It’s easy to see that when we see 10, 15, or 20 patients in a given day, our clerical burden amounts to upwards three hours on the computer. Every. Single. Day. It’s easy to see how this relates to physician burnout and unhappiness. Remember that this job should be both exciting and rewarding.
That’s why it’s so important that we find ways to automate the text that we repeatedly use in our clinical documentation. This page contains my own personal list of templates I use for documenting patient encounters. These “smart-phrases” or “dot-phrases”, as they’re called in some electronic medical record systems, are necessary for me to do my work efficiently.
But first, some caution:
When used without care or thought, word templates dilute the medical record. This is confusing and meaningless at best. It’s dangerous for patients at worst.
History and Physical Template (General Inpatient)
Chief Complaint
Subjective
Social History
Medications
Allergies
Objective
Vitals: T: HR: BP: R: O2:
Physical Exam:
Constitutional:
HEENT:
Lymph:
Lungs:
Cardiovascular:
Abdomen:
Extremities, Including Pulses:
Neuro (mental status, motor, sensory, cranial nerves, coordination):
Psych
Notable Laboratory Results, Radiologic Studies, EKG Interpretations, etc.:
Assessment/Plan
Code Status:
Diet:
Lines/Tubes:
VTE Prophylaxis:
Smoking
.smoke
I advised the patient to quit smoking and I reviewed options such as nicotine replacement, medications, behavioral tools, and support groups. The patient agreed with the potential benefits of keeping a daily log for smoking habits and triggers for increased use.