ecw Weekly User Tip: Save Notes As Template & Building a Template From Scratch

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1 ecw Weekly User Tip: Save Notes As Template & Building a Template From Scratch Templates are a great tool for maximizing documentation efficiency. They can make documentation easier by prepopulating fields that you always add. Conversely, they can make documentation cumbersome if they overextend the basic needs of the visit. The best users of templates often have several versions of the same template in order to keep their templates targeted and reliable and to avoid having to constantly, counterproductively remove items not used. If you find yourself repeatedly adding or free-texting your own personal elements (e.g., exam details, medications, modified anticipatory guidance) after merging a standard template, you may need to create a copy and adapt it to better fit your needs. You can create a template from scratch or save a note as you go. Either method will involve some finagling and, of course, your own personalized modifications. Save Notes As Template If you re particularly happy with a note you ve crafted and would like to reproduce it later, the Save Notes As Template feature allows you to save as you go. 1. Complete your note. In the Progress Notes, click on the green arrow next to Templates.

2 2. Click Save Notes As Template. 3. Name your template. Use the following naming convention when naming your Template: INITIALS Template Name (e.g., MR Abdominal pain). Click OK to save. Using a naming convention allows you to search for your own customized templates easily Leave blank unless template fits only one specific visit type Private setting prevents other users from editing your template Next time you search templates, use your naming convention to view all of your templates.

3 4. Modify as needed. You can modify your new template right away or postpone for later. Click Yes to view/edit now Click No to view/edit later 5. If you selected, No: To view later, go to File > Templates. If you selected Yes, go to step 7.

4 6. Search for your template. Double-click on your template to view/edit. 7. Clean up your template. Clear or modify any information that was specific to your previous patient. WARNING: Leaving any patient specific information will adversely affect your or other users notes (e.g., improper information population, vitals being replaced by template vitals, other users notes populating with template vitals.) Do not keep any template information in the following patient-specific sections: o Current Medication o Medical History o Allergies o Surgical History o Hospitalization o Family History o Social History o Vitals Do not keep lab orders, diagnostic imaging orders, or procedure orders in your template. 8. Don t worry. Template is saved real-time. 9. Update frequently or as needed. Building a Template From Scratch 1. Using any of your patients seen, regardless of visit content, repeat steps 1-6 of Save Notes As Template. 2. When you get to step 3, use the intended name of the template you wish to create from scratch. 3. Search for your template. Double-click on your template to view/edit.

5 4. From your open template, merge a blank template (here s the finagling bit). Click Templates at the bottom. 5. Search for blank template.

6 6. Click All Options. 7. Click on the green arrow next to Merge Templates.

7 8. Click Copy Template. 9. Select Yes to overwrite existing information.

8 10. Voila! Here is your blank canvas! 11. Things to remember when creating a template: Do not save any template information in the following sections, regardless of relevance: o Current Medication o Medical History o Allergies o Surgical History o Hospitalization o Family History o Social History Do not order lab, diagnostic images, or procedures in your template. 12. Go crazy! But don t go crazy. A common mistake with creating templates is building your ideal visit. You know you ve added too much if you find yourself removing the same elements at least 30-40% of the time. Keep your template bare bones and then add if you find yourself adding the same elements over and over again. 13. Don t worry. Template is saved real-time. 14. Update frequently or as needed.