Embed Size (px)
Citation preview
Disclaimer - Content Use Policy: The content in eCW Weekly Users Tips is intended for electronic medical record (EMR) optimization purposes for use by healthcare providers of Children’s Health Centers of Children’s National Medical Center. The workflows described may be specific to the EMR system configurations and security settings of Children’s Health Centers. Please use your discretion and adapt to better fit your practice. Children's National Medical Center is not responsible for the use of this content outside of Children’s Health Centers.
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.
Disclaimer - Content Use Policy: The content in eCW Weekly Users Tips is intended for electronic medical record (EMR) optimization purposes for use by healthcare providers of Children’s Health Centers of Children’s National Medical Center. The workflows described may be specific to the EMR system configurations and security settings of Children’s Health Centers. Please use your discretion and adapt to better fit your practice. Children's National Medical Center is not responsible for the use of this content outside of Children’s Health Centers.
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.
Disclaimer - Content Use Policy: The content in eCW Weekly Users Tips is intended for electronic medical record (EMR) optimization purposes for use by healthcare providers of Children’s Health Centers of Children’s National Medical Center. The workflows described may be specific to the EMR system configurations and security settings of Children’s Health Centers. Please use your discretion and adapt to better fit your practice. Children's National Medical Center is not responsible for the use of this content outside of Children’s Health Centers.
4. Modify as needed. You can modify your new template right away or postpone for later.
5. If you selected, No: To view later, go to File > Templates. If you selected Yes, go to step 7.
Click No to view/edit later
Click Yes to view/edit now
Disclaimer - Content Use Policy: The content in eCW Weekly Users Tips is intended for electronic medical record (EMR) optimization purposes for use by healthcare providers of Children’s Health Centers of Children’s National Medical Center. The workflows described may be specific to the EMR system configurations and security settings of Children’s Health Centers. Please use your discretion and adapt to better fit your practice. Children's National Medical Center is not responsible for the use of this content outside of Children’s Health Centers.
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.
Disclaimer - Content Use Policy: The content in eCW Weekly Users Tips is intended for electronic medical record (EMR) optimization purposes for use by healthcare providers of Children’s Health Centers of Children’s National Medical Center. The workflows described may be specific to the EMR system configurations and security settings of Children’s Health Centers. Please use your discretion and adapt to better fit your practice. Children's National Medical Center is not responsible for the use of this content outside of Children’s Health Centers.
4. From your open template, merge a blank template (here’s the finagling bit). Click Templates at the bottom.
5. Search for blank template.
Disclaimer - Content Use Policy: The content in eCW Weekly Users Tips is intended for electronic medical record (EMR) optimization purposes for use by healthcare providers of Children’s Health Centers of Children’s National Medical Center. The workflows described may be specific to the EMR system configurations and security settings of Children’s Health Centers. Please use your discretion and adapt to better fit your practice. Children's National Medical Center is not responsible for the use of this content outside of Children’s Health Centers.
6. Click All Options.
7. Click on the green arrow next to Merge Templates.
Disclaimer - Content Use Policy: The content in eCW Weekly Users Tips is intended for electronic medical record (EMR) optimization purposes for use by healthcare providers of Children’s Health Centers of Children’s National Medical Center. The workflows described may be specific to the EMR system configurations and security settings of Children’s Health Centers. Please use your discretion and adapt to better fit your practice. Children's National Medical Center is not responsible for the use of this content outside of Children’s Health Centers.
8. Click Copy Template.
9. Select Yes to overwrite existing information.
Disclaimer - Content Use Policy: The content in eCW Weekly Users Tips is intended for electronic medical record (EMR) optimization purposes for use by healthcare providers of Children’s Health Centers of Children’s National Medical Center. The workflows described may be specific to the EMR system configurations and security settings of Children’s Health Centers. Please use your discretion and adapt to better fit your practice. Children's National Medical Center is not responsible for the use of this content outside of Children’s Health Centers.
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.
