Starting as an NP student, I realized the value of using templates for my notes. It ensures that I don't miss any important points - prompting me to a through assessment every time - no matter how tired/distracted/______ I am.
I've also learned to set it up with default normative answers - so the only things I need to edit are the abnormal findings of note. This lets me be efficient so I can spend more time with talking with patients and less time at my computer.
Finally, making such templates in an easily adapted format ie. Word, allows me to 'cut & paste' into any Electronic Medical Record (EMR) I might be using. If I'm lucky, said EMR will also let me save the template as a default in its own database. This is pretty often the case.
I've also learned to set it up with default normative answers - so the only things I need to edit are the abnormal findings of note. This lets me be efficient so I can spend more time with talking with patients and less time at my computer.
Finally, making such templates in an easily adapted format ie. Word, allows me to 'cut & paste' into any Electronic Medical Record (EMR) I might be using. If I'm lucky, said EMR will also let me save the template as a default in its own database. This is pretty often the case.
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This is template for an initial psychiatric evaluation (i.e. 90791 or 90792) in an emergency room or inpatient setting, though could be adapted to suit any care environment, I imagine.
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Using the Template
There are three options for inputting data:
After you've got the template completed to your satisfaction - 'select all' text (Ctrl A) and change the font color to black. And you are good to go!
If you use this template, I'd love to hear your thoughts, feedback, recommendations!
No one person can know everything and a good documentation process can always be improved.
There are three options for inputting data:
- Fill-in-the-blank: Change the text prompt by typing in the text you want
- Drop down menu: Self-explanatory really. If you don't see an option yo like there is always Option 3.
- Free Type text: It is still a word document after all - type whatever you want - where ever you want. Write a novel if you'd like.
After you've got the template completed to your satisfaction - 'select all' text (Ctrl A) and change the font color to black. And you are good to go!
If you use this template, I'd love to hear your thoughts, feedback, recommendations!
No one person can know everything and a good documentation process can always be improved.
