I have worked with at least 20 or 30 customers over the past two and a half years and there is one thing that resonates among clients…the notes in EHR need to be more focused. In fact, it seems like Allscripts is gradually moving in that direction because with every new noteform release, there seem to be more focused “Complete” body system exam forms available. These forms have evolved over time from the initial “General Multi-system” to the “General Complete Multi-system” form. This was a great move since prior to the “complete” version being rolled out I spent countless hours adding more appropriate verbiage to the “normals” per the client’s request. I have also noticed an increase in the number of specialty specific multi-system forms. As we all know, most specialties are different and have different needs in terms of their exam documentation so remembering that “one size does not fit all” is extremely important.
Now that we are moving in the right direction with forms, we should also keep in mind that the note templates are just as important. When designing note templates I always start by asking each specialty what conditions (diagnoses) they see the most. Armed with this information, I am then able to format specific note templates accordingly. You may wonder how this is helpful since most patients present with more than one condition. I have been able to address this problem by developing note templates that encompass the most common presenting conditions such as Asthma/COPD and Diabetes/Hypertension/Hyperlipidemia. For providers, this approach streamlines what they see in their note template from beginning to end.
For the HPI section, instead of using the auto-config functionality, I default in the applicable forms per condition. For Physical Exam, I use one of the newer body system specific general complete forms such as the Pulmonary Complete from for an Asthma/COPD note. Under the Results Data and Discussion/Summary sections of the notes, I pull in applicable forms as well, such as Chest X-rays and/or Asthma and COPD Discussion forms. By making these changes, I am able to offer providers more focused note templates, which have been well received.
While I freely admit, this approach may not work for every specialty, and may not be pleasing to providers who have never used an EHR, it is certainly worth considering. It would also be helpful to show providers what condition specific notes look like in comparison to the more general notes since most people are visual. For many providers just knowing what other set up options are available with V11 note can ease frustration and generate excitement over the possibilities!