Medical providers are increasingly required to keep complete and detailed charting documentation, which in the case of an audit could affect claims reimbursement. These guidelines require thorough documentation of the patient visit, and may include a detailed history of the patient. For the typical busy provider the large pieces of text in the note that reoccur based on common visit types can be time consuming to free-hand or type in the chart while engaging the patient in the exam room. Practice Fusion’s charting templates are customizable forms that providers can easily apply to their SOAP notes (through clicks or keyboard commands), which help automate entry of redundant narratives and enable the provider to key in just the specific variable data elements about that patient. This way the provider can spend less time typing and clicking, and focus on what’s most important: the patient and his/her health.
Templates exist in many parts of the Practice Fusion EHR, including medical charting, SOAP notes, intake forms, flowcharts and lab orders. Templates can be easily customized to fit the many different types of specialty and size practices that use our EHR. We also foster a community of sharing, where practices can share their templates with other providers in our template library.
These tools help make charting visit notes simple and easy, and eliminate the need to play catch up after the work day.
What are electronic health record templates?
A well-designed template is short, easy to use, includes pertinent positives and negatives, incorporates guidelines, and offers mnemonics to help deliver evidence-based care under the time constraints of a busy office. The residue of the template in the chart should be a complete note to mark the clinical encounter that meets documentation standards with minimal extra typing and no unnecessary chart bloat. They also have the potential to standardize care further, automate reminders and investigations, and reduce systemic resource wasting by recommending appropriate tests and discouraging inappropriate ones.